UTERINE ATONY - CASE STUDY - Edited

HOLY ANGEL UNIVERSITY 1
I. INTRODUCTION
Patient Diagnosis:
Acute blood loss secondary to early postpartum hemorrhage secondary to
transient uterine atony; anemia secondary corrected status post NSD.
Description of the disease:
According to Wormer, et. al. (2019), postpartum hemorrhage is excessive
bleeding following the birth of a baby. About 1 to 5 percent of women have postpartum
hemorrhage and it is more likely with a cesarean birth. Hemorrhage most commonly
occurs after the placenta is delivered. The average amount of blood loss after the birth of
a single baby in vaginal delivery is about 500 ml (or about a half of a quart). The average
amount of blood loss for a cesarean birth is approximately 1,000 ml (or one quart). Most
postpartum hemorrhage occurs right after delivery; but it can occur later as well. Once a
baby is delivered, the uterus normally continues to contract (tightening of uterine
muscles) and expels the placenta. After the placenta is delivered, these contractions help
compress the bleeding vessels in the area where the placenta was attached. If the uterus
does not contract strongly enough, called uterine atony, these blood vessels bleed freely
and hemorrhage occurs. This is the most common cause of postpartum hemorrhage.
School of Nursing and Allied Medical Sciences

Recent trends, innovations, and/or refinements in treatment:
A study from South Africa, entitled Rectal Misoprostol versus Intramuscular
Oxytocin for Prevention of Post Partum Hemorrhage by Shrestha A, Dongol A, Chawla
CD, Adhikari R. (2011), compared a combination of intramuscular syntometrine injection
and oxytocin infusion to rectal misoprostol and found that those who received
misoprostol had a statistically significant reduction in bleeding and further medical co-
interventions to control the bleeding.
The results of the study further showed that Misoprostol is an efficacious and safe
alternative to conventional utero-tonic agents like Oxytocin in active management of
third stage of labor especially in developing countries at community level and at the
peripheral centers. It is as effective in prevention of postpartum hemorrhage as
conventional utero-tonic like Oxytocin, with the same incidence of side effects. So, it is
worthy to use rectal misoprostol as an alternative to Oxytocin.
Furthermore, there is a recent study entitled “Modified Pereira Suture as an
Effective Option to Treat Postpartum Hemorrhage due to Uterine Atony” by Braga J., et
al. (2019) revealed that a modified suture as an effective treatment for postpartum
hemorrhage secondary to uterine atony. In this study, the researchers have included two
cases of postpartum hemorrhages. In the first case, a 45-year-old healthy woman, G2P0,
after fetal delivery uterine atony suddenly occurred whilst the second case is a 31-year-

old healthy woman, few hours after a cesarean section procedure, the emergency team
was called due to active vaginal hemorrhage. A modified uterine Pereira suture was
performed using delayed, absorbable suture thread with effective control of the
hemorrhage to both cases. Both of the patients had fully recovered, and the ransvaginal
sonography revealed a normal uterus with normal uterine artery impedance.
The suture performed was a combination of the B-Lynch and the Alcides Pereira
techniques. A blunt, 70 mm semicircular needle, mounted with a Vicryl 1 (polyglactin
910) absorbable suture, was used to puncture the uterus 2–3 cm from the right lower edge
of the uterine incision and 2–3 cm from the right lateral border. The suture was threaded
through the uterine cavity to emerge at the upper incision margin, located 2–3 cm above
and 3–4 cm from the lateral border.
Subsequently, the surgical thread was passed over to compress the uterine fundus
3–4 cm from the right cornual border and pulled under moderate tension, assisted by
manual compression. The length of the suture was passed back posteriorly through the
same surface marking as on the right side, the suture lying horizontally. Additionally, the
suture was fed through posteriorly and vertically over the fundus to lie anteriorly and
vertically compressing the fundus on the left side, as occurred on the right. The needle
was passed in the same fashion on the left side through the uterine cavity and out 2–3 cm
anteriorly and below the lower incision margin on the left side being then finished with a
tight knot. After that, a series of transverse circular sutures of multifilament absorbable

Vicryl 1 were placed around the uterus.
The placement of the sutures involved a series of bites inserted superficially,
taking only the serous membrane without penetrating the uterine cavity, to anchor and
tighten the longitudinal sutures (described above). Three or four transverse circular
sutures were placed, starting in the anterior wall of the uterus, crossing the broad
ligament toward the posterior aspect of the uterus, then crossing the opposite broad
ligament toward the anterior aspect and tying the suture over the anterior aspect of the
uterus. When the suture crossed the broad ligament, we selected an avascular area to
ensure that the Fallopian tube, the utero-ovarian ligament, and the round ligament were
not inside the suture. The last transverse circular suture was placed in the lower uterine
segment.
Statistics (Local & International)
Local
As stated by its vital statistics report, in the year 2011 to 2013, postpartum
hemorrhage and uterine atony are included in the top 5 causes of maternal death in the
Philippines. In the year 2011, there are a total of 252 deaths caused by postpartum
hemorrhage; in the year 2012, there are a total of 222 deaths caused by postpartum
hemorrhage; and in the year 2013, there are a total of 211 deaths caused by postpartum
hemorrhage.

International
According to the World Health Organization, postpartum haemorrhage (PPH) is
the leading cause of maternal mortality, accounting for about 35% of all maternal deaths.
Between 1990 and 2010, there was a global reduction in maternal deaths and the maternal
mortality ratio (MMR) from 543.000 and 400 per 100,000 live births to 287,000 and 210
per 100,000 live births respectively. However, developing countries continue to
experience higher numbers of maternal deaths compared to developed countries.
In 2010, the MMR in developing countries was 240 per 100,000 live births (284,
000 maternal deaths) compared to 16 (2,200 maternal deaths) in developed countries.
Thirty-five countries have been identified as either making insufficient or no progress
towards achieving the Fifth Millennium Development Goal (MDG5), which aims to
reduce the global maternal mortality rate by 75% from 2000 to 2015.

Student Centered Objectives:
At the end of the study, the student nurses would be able to apply appropriate
nursing care of at-risk/high risk/sick clients during childbearing and childrearing years
through:
1. Integration and application of nursing concepts, theories, and actions.
2. Application of the nursing process specifically assessment, diagnosis, formulation
of plan of care, implementation of safe and quality nursing interventions and
evaluation with the patient.
3. Application of evidenced-based practice when providing nursing care and
preventing injury to at-risk/high risk mother and sick child.
4. Ensurance of working relationships with at-risk/high risk patients based on trust,
respect and shared decision making using appropriate
communication/interpersonal techniques/strategies.
5. Documentation of patient’s response/nursing care services and outcomes of
nursing care rendered.
6. Ensuring the completeness, integrity, safety, accessibility, and security of
information.
7. Adherence to protocol and principles of confidentiality in safekeeping and
releasing of records.
8. Collaboration with other members of the health team in the implementation of
programs and services.
9. Maintenance of a positive practice environment.

10. Assuming responsibility for life-long learning, own personal development and
maintenance of competence.
11. Customizing nursing interventions based on Philippine culture and values.
12. Usage of appropriate technology to perform safe and efficient nursing activities.
Patient Centered Objectives:
At the end of the study, the patient would be able to:
1. Accept and welcome student nurses from Holy Angel University
2. Establish rapport with the student nurses
3. Participate in assessment phase
4. Verbalize willingness to participate in nursing interventions provided by the
student nurses
5. Cooperate with student nurses with ease and comfort
6. Participate in implementation phase
7. Acquire knowledge from the health teachings rendered by the student nurses
appropriate for his/her condition

II. RELEVANT NURSING THEORIES
The nursing students utilized the maternal role attainment theory from Ramona T.
Mercer throughout the process of the study. According to this theory, maternal role
attainment is an interactional and developmental process that occurs over time wherein
the mother becomes attached to her infant, acquires competence in the caring task
involved in her role, and expresses pleasure and gratification in the role. The student
nurses utilized the theory because their client is an adolescent who recently delivered a
child and experienced labor and delivery complications specifically early post-partum
hemorrhage. Due to her early age of unplanned pregnancy, attaining her maternal role
would be difficult because she is more focused on her own developmental tasks rather
than herself as becoming a mother. According to Neeson, et. al. as cited in Alligood,
(2018), appropriate and timely utilization or application of maternal role attainment can
result to positive maternal outcome even among adolescents who became pregnant. In
support with the utilization of the theory in this study, another research study from
Asgharipour, Fasanghari, Kordi, (2019), utilized Mercer’s maternal role attainment
among primiparous women with unplanned pregnancy through analysis of the effects of
maternal role promoting program.
These research studies served as a basis for the student nurses to utilize and apply
Mercer’s theory of maternal role attainment. Maternal role attainment highlights on the
process of helping the mother attain her role. There are three levels of interacting
environments that was identified on the theory of Mercer; (1) microsystem or the family
and friends of the mother; (2) mesosystem or the community where the mother is at; (3)

macrosystem or the society at large. These interacting environments have a specific role
and function that helps on the process of becoming a mother (BAM). They differ based
on their functions or tasks in promoting maternal role attainment. The main function of
the microsystem is the immediate system in which maternal role attainment occurs. This
includes the factors such as family-functioning, mother-father relationship, social
support, economic status, family values, and stressors. These variables interact with other
variables that affect the the process of BAM. Likewise, this system is also the most
influential on maternal role attainment. It emphasized the importance of the father’s role
in maternal attainment as it helps to “diffuse tension developing within the mother-infant
dyad” (Mercer,2006). While mesosystem on the other hand, encompasses, influences,
and also interacts with the persons included in the microsystem. The interaction within
the mesosytem holds a great responsibility and could affect on the developing maternal
role and the child. It includes day care, school, work setting, places of worship, and other
entities within the immediate community. Lastly, the macrosystem, refers to the general
prototypes existing in a specific culture and community. This includes the social,
political, and cultural influences on the other two systems. An example of this is natural
laws regarding women and child and health priorities that influence maternal role
attainment.
The nursing process found and stated on Mercer’s theory is a four stage process of
acquisition. They are: anticipatory, formal, informal, and personal. Currently, the patient
gave birth to a baby already. Applying the case, the patient is on the formal stage of
acquisition which begins once the baby is outside the utero and it includes learning and

taking the role of the mother. Role behaviors are guided by formal, consensual
expectations and other’s in the mother’s social system. Since the patient is still on
recovery after the complications and delivery, maternal role attainment and transitioning
to providing infant care may be a challenge to her. This is where the student nurses would
promote becoming a mother and guide the patient for a better mother and child outcomes
Figure 1. Interacting environments that affect the process of becoming a mother.

(Mercer & Walker, 2006)
Application of the Theory

Community Interacting Environment

Figure 2. Community interacting environment
The community interacting environment guides the patient on becoming a mother
that is currently on her formal stage of maternal role attainment. These includes public
health nursing, health care facilities, recreational facilities, places of worship, child care
centers, and protective social services. Therefore, social role preparation, mother-infant
attachment promotion, infant care giving instructions, and therapeutic relationships.
Interventions focused on social role preparation:
Maternal social role preparation includes building up of confidence among
mothers through role supplementation. Since community at large includes health care
facilities, the student nurses, while at the health care facility with the patient, provided
health education about the importance of preparing herself on her role from being a
mother who experienced pregnancy complications into becoming a mother with
confidence on caring for her infant.

Interventions focused on mother-infant attachment promotion:
Infant attachment promotion includes interventions specifically health teachings
about the benefits and the need to breastfeed, and also the promotion of skin to skin
contact. Since the mother is an adolescent teenager, she is currently on the formal stage
of acquisition therefore she is dependent on what others would teach her or advise her to
do. Through promotion of infant attachment, the mother can easily recover from her
previous condition and become a mother in the near future.
Interventions focused on infant care giving instructions:
Infant care giving instructions can be acquired from the health care facilities and
from the community health centers. The role of the student nurses that highlighted on
infant care giving are: the promotion of counseling, and compliance with the patients
OPD (outpatient department) follow up checkup wherein specific infant care giving
instructions would be provided on the patient
Interventions focused on nurse-patient therapeutic relationships:
Therapeutic relationships between the patient is a must so that the patient would
have confidence in practicing infant care giving tasks, her role as a mother, and becoming
a mother. Since the patient experienced a pregnancy complication, establishing a
therapeutic relationship and rapport with the patient can also promote maternal recovery.
Immediate Family and Friends Environment

Figure 3. Family & Friends interacting environment
The immediate family and friend’s environment provides the mother to have a
better support group and guidelines for maternal and infant care and towards to their
behavior. Social support group includes: continuity of cultural customs, physical and
social support, knowledge and skills, family continuity and affirmation as a mother.
Interventions focused on Maternal Physical Recovery:
Maternal Physical Recovery provides the recovery regimen that would help the
patient to achieve her optimum health to fully focus on her maternal role to her infant.
The student nurses provided nursing care plans which would help the patient to recover to
cope up as soon as possible to her proceeding maternity roles.
Interventions focused on Maternal Care-of-Self Promotion
The Maternal care of Self-promotion prevents the patient from stressing too much

on her infant that might lead to the mother putting her needs aside. Since it is the first
time that the mother would take care of an infant, the patient might get overwhelmed with
her responsibility subconsciously setting aside her own optimum health. Through this
promotion model, and with the help of student nurses of providing health teachings, this
could prevent such possibilities and will resume the maternal care needed for her infant.
Interventions focused on Maternal Well-Being Promotion
The maternal well-being promotion entails the patient to be stable both physically
and mentally to ensure her own and infant health. Since the patient is still a teenager, it is
important that supporting her physically and mentally would help her to cope up with the
normal stresses in life and can work productively as needed for maternal and infant care.
Society at Large Environment

Figure 4. Society at large
The roles of the Society at large consist of the laws affecting childbearing
decisions and the laws affecting maternal-child safety. The patient was on the formal
stage which means that the interventions were focused on the behavior of the of the
patient towards making her own decision.
Interventions Focused on Maternal/Social Role Preparation:
The student nurses provided health teachings about the different laws affecting
maternal and child to the patient. The laws include rooming-in and breastfeeding act of
1992 which promotes breastfeeding in the Philippines. Another law is the expanded
breastfeeding promotion act of 2009 which signed to support, protect and encourage
women who are breastfeeding working mom. Another law is the responsible parenthood
and reproductive health act of 2012 which guarantees universal access to methods of
contraception, fertility control, sexual education, and maternal care. Lastly, is the
mandatory infant and children immunization, which requires that all children under five

years old be given basic immunization against vaccine-preventable diseases. With these
laws, the patient will now then be aware of her rights as a mother and the rights of her
child. This would then help her in the preparation of her maternal/social role and would
guide her in becoming a mother to her child.
III. NURSING HISTORY
1. BIOGRAPHIC DATA
i. Patient’s name: Manalo, Sheila Cubao
ii. Address: 27 purok 1 Mandasig, Candaba, Pampanga
iii. Age and Birth date: 18 y/o, 01/28/2002
iv. Birth place: San Fernando, Pampanga
v. Gender: Female
vi. Marital Status: Single
vii. Race, Ethnic origin: Fil, Roman Catholic
viii. Occupation: None
ix. Dialect: Kapampangan, Tagalog
x. Chief Complaint/s: Bleeding
2. LIFESTYLE
i. Personal Habits: Cooking
ii. Diet/Nutrition: Vegetarian
iii. Sleep/Rest Pattern: 9:00 pm - 7:00 am; 6:00 pm - 5:00 am

iv. Exercise: Walking 15 mins / day
v. Activities of Daily Living (ADLs): Walking, feeding, dressing and grooming,
toileting, bathing, and transferring.
vi. Instrumental Activities of Daily Living: Managing transportation, shopping
and meal preparation, house cleaning and home maintenance, managing
communication, and managing medications.
vii. Recreation/Hobbies: Walking and sewing
3. FAMILY HISTORY OF ILLNESS
i. Both schematic diagram and narrative explanation of the whole diagram
Diagram 1. Genogram
Legend:
- Index patient
- Hypertension
Diagram 1. Genogram
All of the family members on both sides are said to be healthy. Ol, father of the index
client, was diagnosed with hypertension (date can not recall) at their health center and

now currently taking his medicines for maintenance.
4. PAST MEDICAL HISTORY
i. Immunization: Complete immunization
ii. Childhood Illness: Chicken pox at 12 y/o
iii. Accidents or Injuries: 2nd degree burn located at left hand at 15 y/o
iv. Serious or chronic illness: none
v. Hospitalization: none
vi. Operations: none
vii. Obstetric history: G1P1 (1001), uterine atony
Last menstrual period: May 15, 2019
viii. Last examination date: February 25, 2020 at Jose B. Lingad Memorial
Regional Hospital
ix. Allergies: none
x. Current and previous medications:
>Cefuroxime 500 mg / tab, 1 tab BID
>Ferrous Sulfate 1 tab OD
>Calcium Carbonate 1 tab BID
5. HISTORY OF PRESENT ILLNESS
i. Incision pain after vaginal delivery (February 24, 2020) located at the
perineum (fourchette), pain upon movement, and pain scale of 8/10
ii. Vaginal bleeding after delivery and was referred to JBLMRH.

IV. PHYSICAL ASSESSMENT (IPPA- Cephalo-caudal Approach)
The patient was admitted last February 25, 202 0. The student nurse met
the patient last February 26, 2020. When the student nurse visited her, she
was already on her last day post-operative. The student nurses introduced
themself, told her they was assigned to take care of her. I stated my purpose and asked
permission to do physical examination. Although she seems tired, in pain and
quite depressed, she consented me in doing physical examination.
GENERAL APPEARANCE
The patient is in sitting position ; she was approximately 1l0bs
a n d approximately 5 feet and 2 inches tall. She was neat, well groomed and no foul
odor. She grimaces every time she moves. She is slightly pale, seems tired, with labored
breathing, b e c a u s e o f p a i n , q u i t e i r r i t a b l e
b u t c o o p e r a t i v e . V i t a l s i g n s u p o n a s s e s s m e n t a r e a s follows:
BP- 100/80mmHg, PR-70bpm, RR-22cpm, Temp- 35.4 C
Assessment
RMH Assessment
February 26, 2020
The skin appears pale, warm to touch. The
Skin complexion is fair, slightly dry but with good
skin turgor. There is no skin lesions found
Hair The hair is long and black in color, it is dry.
The nails on both hands and feet are well-
trimmed, slightly pink in color and are convex
Nails
curved. Blanch test was made to test for capillary
refill and there is prompt return of color.
The head is normal in size. No lesions neither
Head mass was noted upon inspection. There is
symmetry in facial movements

Black in color. The eyelids are symmetrically

aligned and there are equal movements.
Conjunctivas are shiny, smooth and pale pink in
color. Pupils constrict promptly when lighted. I
Eyes and vision
also asked the patient to read the note posted on
the wall which was approximately 12 feet away
and she read it correctly. No deviation on the six
ocular movements.
Color is same as facial skin. There is symmetry
in size and position. Auricles are mobile, firm
Ears and hearing and not tender. The pinna recoils after it is
folded. The patient hears and responded well to
whispered voice and watch tic test.
Color is same of as the facial color, located in
the middle of the face. It is symmetric and
Nose and sinuses
straight. No discharge, flaring lesions and
tenderness and noted.
The lips slightly pale in color, soft, moist, and
smooth in texture. The gums are pink and there
are 29 adult teeth, the enamel are yellowish in
Mouth and oropharynx
color. Tongue is smooth and (-) for lesions. The
palate, uvula, oropharynx and tonsils appear
smooth and pink in color.
Asked patient to move the head from left to right
and flexed and hyper extended, (+) for smooth
Neck movements, (-) for discomfort and the
movements are coordinated. (-) for lymph nodes
upon palpation on the thyroid gland
RR: 22cpm
Student nurses observed the movements of the
Thorax and lungs
chest and breathing pattern. (+) for labored
breathing due to pain.
BP: 110/80mmHg
Heart HR: 70bpm
No other abnormal sounds heard
(+) symmetric pulse volume and full pulsation
on peripheral pulses of extremities. Jugular vein
Peripheral vascular system in not distended. Skin is warm to touch, no
edema found on both upper and lower
extremities.
Claimed to be painful due to engorgement. The
right breast is more engorged than the left. The
Breast and axillae
areola appears dark brown. The nipples are
round.

(+) dry, intact dressing. The wound is still

Abdomen painful so student didn’t have a chance to palpate
other organ on the surrounding area.
Compared the size, shape and color of the one
side of the body to the other side, there is equal
sizes and color on both sides. (-) for contractures,
Muscular-skeletal system tremors, deformities, swelling and tenderness.
Movements are coordinated and are normally
firm. There is equal strength on both sides of the
body.
(+) lochia rubra moderate in amount and smells
like menstrual blood. The perineum is slightly
Genital and anal area
edematous. No abnormalities found on the anal
area.
V. DIAGNOSTIC AND LABORATORY PROCEDURES ORDERED
Complete Blood Count

Date ordered: February 25, 2020

Date results released: February 25, 2020

DIAGNOSTIC INTERPRETATION OF
and INDICATORS/PURPOSE RESULT NORMAL RESULTS and
LABORATORY VALUES IMPLICATION TO
PROCEDURE (used in the NURSING CARE
hospital)
Hemoglobin To measure HOLY
the totalANGEL UNIVERSITY
59mg/dL 120-160 The results23
indicates
amount of the oxygen- mg/dL lower than normal
carrying protein in the range. It usually
blood, which generally indicate anemia. The
reflects the number of nurse must monitor
red blood cells in the oxygen saturation.
blood
Hematocrit To measure the 0.18% 0.37% The result of 0.18% in
percentage of your total -0.47% hematocrit means the
blood volume that percentage of
consists of red blood red blood cells is
cells. extremely below
the lower limits of
normal.
RBC T count the actual 2.0 x 4.0 – 5.4x The result is below than
number of red blood 109/L) 109/L) the normal range. The
cells in your blood nurse must watch out
sample. for dizziness, weakness
and light-headedness
when changing
position.
WBC May be included as part 16.6 x 4.0-10.0 x The result exceed the
of the CBC or may be 109/L 109/L normal range. Increased
done in follow up if the in white blood cell can
WBC count is high or be an indication of
low. The WBC infection.
differential identifies
and counts the number
of the five types of
white blood cells
present
Differential Count
Neutrophils First cells to migrate to 83.5 55.0-65.6 The result is elevated.
the site of the infection Neutrophil blood levels
to begin killing the increase naturally in
invading microbes. response to infections,
injuries, and other types
of stress.
Lymphocytes Act to recognize 10.4 25-35 The result means,
antigens, produce lymphocyte count in
antibodies, and destroy bloodstream is lower
cells that could cause than normal. Nurse
damage must watch out for
possible infection.
Monocytes Fight certain infections 5.8 3.0-6.0 The results is within
and help other white normal limits.
blood cells remove
dead or damaged
School
tissues, of Nursing
destroy cancer and Allied Medical Sciences
cells, and regulate
immunity against
foreign substances.
Eosinophils Are crucial for 0.2 2.0-4.0 The result is lower than
Immunology/Serology results form

hospital)
HBsAg (rapid) To determine if Non- The result indicates no
someone is infected reactive hepatitis B surface
with the hepatitis B antigen was found
virus
Syphilis Are used to screen for Non- The result indicates a
and diagnose infection reactive person not
with Treponema having syphilis
pallidum
ABO Typing To determines a A+ The patient blood type
person's blood type is “A” positive. If blood
transfusion is needed A
positive can give red
blood cells to other A
positive and AB
positive recipients.
Those with A positive
can only receive red
blood cells from A or O
blood types.
Complete Blood Count


hospital)
Hemoglobin To measureHOLYthe totalANGEL 120-160 The result 25
UNIVERSITY
92mg/dL remains
amount of the oxygen- mg/dL below the normal range.
carrying protein in the It usually indicate
blood, which generally anemia
reflects the number of
red blood cells in the
blood
Hematocrit To measure the 0.28% 0.37% The result indicates
percentage of your total -0.47% slightly elevation but
blood volume that remains below the
consists of red blood normal range
cells.
RBC T count the actual 3.24 x 4.0 – 5.4x The result was elevated
number of red blood 109/L) 109/L) but remains below the
cells in your blood normal range
sample.
WBC May be included as part 10.3 x 4.0-10.0 x The results decreases
of the CBC or may be 109/L) 109/L but remains slightly
done in follow up if the more than normal range
WBC count is high or
low. The WBC
differential identifies
and counts the number
of the five types of
white blood cells
present
Differential Count
Neutrophils First cells to migrate to 70.8 55.0-65.6 The results decreases
the site of the infection but remains more than
to begin killing the normal range
invading microbes.
Lymphocytes Act to recognize 19.0 25-35 The result increases but
antigens, produce did not reach the
antibodies, and destroy normal range
cells that could cause
damage
Monocytes Fight certain infections 6.0 3.0-6.0 The result remains
and help other white within the normal rage
blood cells remove
dead or damaged
tissues, destroy cancer
cells, and regulate
immunity against
foreign substances.
Eosinophils Are crucial for 3.8 2.0-4.0 The result increases and
combatting parasitic is now within normal
infections and range
inflammatory
Schoolsuch
processes, of Nursing
as and Allied Medical Sciences
allergic reactions.
Basophils Type of white blood 0.4 0.0-1.0 The result increases and
cell that fights off remains in normal
VI. NURSING RESPONSIBILITIES BEFORE, DURING AND AFTER
PROCEDURE
Complete Blood Count provides valuable information about the blood and to
some extent, the bone marrow, which is the blood-forming tissue. Based on the patient’s
condition, the purpose of complete blood count is to diagnose anemia and to monitor
treatment for anemia.
Nursing responsibility before the procedure is to explain the test. Explain that
slight discomfort may be felt when the skin is punctured. Encouraged to avoid stress if
possible because altered physiologic status influences and changes normal hematologic
values. Explain that fasting is not necessary. However, fatty meals may alter some test
results as a result of lipidemia.
During the procedure, a needle is inserted into the vein, and the blood is collected
in an air-tight vial or a syringe, once the blood has been collected, the needle is removed.
Nursing responsibility is to stop any bleeding. Apply manual pressure and dressings over
puncture site.
After the procedure the nursing responsibility is monitor the puncture site for
oozing or hematoma formation and instruct to resume normal activities and diet.
Immunology is the study of the body's immune system and its functions and
disorders. Serology is the study of blood serum. Immunology and serology laboratories
focus on Identifying antibodies. These are proteins made by a type of white blood cell in
response to a foreign substance in the body and investigating problems with the immune
system. These include when the body's immune system attacks its own tissues and when

a body's immune system is underactive.
Nursing responsibility for HBsAg test before procedure is explain the test. Select
the finger for puncture, usually the fourth finger. Clean the skin area to be punctured with
the alcohol pad. Allow the finger to dry.
Nursing responsibility for HBsAg test during procedure is to allow a drop of
blood to form on the finger. If blood flow is inadequate, gently massage at the base of the
finger to produce sufficient blood volume. Collect 2 drops of blood.
Nursing responsibility for HBsAg test after is to stop any bleeding. Apply manual
pressure and dressings over puncture site.
Nursing responsibility test for syphilis or Rapid Plasma Reagin before procedure
is to explain the test to the patient and instruct it doesn’t need to fast.
Nursing responsibility test for syphilis or Rapid Plasma Reagin during procedure
a nurse is to ensure the needle is on suitable vein and instruct patient to relax its arm.
Nursing responsibility test for syphilis or Rapid Plasma Reagin after procedure,
remove the needle. Hold some pressure on the site for a few seconds then apply an
adhesive bandage to the arm.
Nursing responsibility for ABO Typing before procedures is to explain the
procedure and requires no special preparation is needed.
Nursing responsibility for ABO Typing during procedures is to make sure a drop
of blood from finger is adequate
Nursing responsibility for ABO Typing after procedures hold some pressure with
a clean cotton on the site.

VII. THE PATIENT AND HIS ILLNESS

1. Relevant Anatomy and Physiology
ANATOMY OF UTERUS DURING LABOR & DELIVERY
Uterus

Fundus Body Cervix
Determine Effacement and

characteristics dilatation
of uterine
Uterine
contraction
Wall
Perimetrium Myometrium Endometrium
Reinforces During labor & Site of

myometrium delivery, it implantation
contracts to expel
products of
conception (fetus
& placenta)
During
postpartum,
Well-
myometrium
contracted
contracts to
fundus
constrict blood
vessel
↑ Uterine
hemostatic
function
EXPLANATION
According to Pillitteri (2014), uterus is the hollow organ in the female
reproductive system that holds a fetus during pregnancy. The uterus performs multiple
functions and plays a major role in fertility and childbearing. It has three parts: first is the

body that expands to accommodate the growing fetus. Under this is the fundus, the
palpable portion during pregnancy, its function is to determine the characteristics of
uterine contraction during labor, and to assess that the uterus is returning to its
nonpregnant state after childbirth. And lastly, the cervix which is responsible for
effacement and dilatation during childbirth. The three layers of uterine wall consists of
three separate coats or layers of tissue: the Perimetrium, the outer layer of connective
tissue, reinforces the myometrium and protects the uterus from friction by forming a
smooth layer of simple squamous epithelium along its surface and by secreting watery
serous fluid to lubricate its surface. The Myometrium which is the middle layer of muscle
fibers. During labor & delivery, the myometrium contracts to expel products of
conception also known as the fetus and placenta. While during postpartum, the
myometrium contracts to constrict blood vessels in order to form a well-contracted
fundus that increases the uterine hemostatic function to avoid bleeding. Lastly, the
Endometrium, an inner layer of mucuous membrane and the site of implantation, grows
and becomes so thick and responsive each month under the influence of estrogen and
progesterone that it becomes capable in supporting a pregnancy.
2. Pathophysiology
i. Client Centered
1. Schematic Diagram (Flow Chart)
Patient is Asian, practice of fundal pushing on the second stage of

labor, prolonged labor for 18 hours
Soft
Myometrium fails to contract boggy
uterus
Transient uterine atony
Vaginal
Decreased constriction of blood vessels bleeding
supplying the placental bed from the
placental
site
Decreased uterine hemostatic function
Decreased hypercoagulability (“uterine

healing”) of the uterus
Decreased Proenzyme plasminogen
Decreased type 1 plasminogen Decreased active fibrin

activator inhibitor degrading enzyme plasmin
Acute
blood loss Decreased platelet count and
>500 ml coagulation factors
Early postpartum hemorrhage

Decreased
hemoglobin
Secondary
anemia
Increased heart rate Skin turns pallor

as a compensatory in color and
mechanism of the characteristics due
body with decreased to blood loss and
blood pressure or fluid volume
hypotension deficit
JUSTIFICATION AND EXPLANATION
According to Pillitteri, risk factors of uterine atony leading to post partum
hemorrhage is high among asians and with prolonged process of labor. Applying this
concept to the case of the client, a Filipino G1P1 with a prolonged labor of 18 hours was
identified. Fundal pushing, as stated by World Health Organization (2018), is not
recommended because there is not enough evidence to support its effectivity and can
impose a high risk on the mother and child. Complications specifically perineal
lacerations, uterine rupture, and uterine inversion can affect the maternal and child
outcomes. The client, upon assessment, stated that fundal pushing was prolonged during

her delivery because of her prolonged labor. Therefore, an overstretch or overpressure on
the fundus or myometrium can impose risk for uterine atony. Once the myometrium fails
to contract, palpating the uterus would indicate a “soft and boggy” uterus leading to
transient uterine atony. Transient uterine atony or relaxation of the uterus happens.
However, the myometrium mechanically compresses the blood vessels that supply the
placental bed to promote uterine hemostasis (Gill, 2020). Therefore, if the myometrium
fails to contract, there would be a decreased constriction of blood vessels that supplies the
placental bed which results to vaginal bleeding due to the placental implantation site not
being able to contract and constrict. The uterine hemostatic function is also termed as the
“uterine healing” therefore if it is decreased in function, the compensatory mechanism of
the uterus is also decreased. Uterine hemostatic function promotes hypercoagulability
which is the result of proenzyme plasminogen activation into active fibrin degrading
enzyme plasmin (Brenner,2004). Through this, the local decidual hemostatic factors such
as tissue factor type-1 plasminogen activator inhibitor as well as by systemic coagulation
factors such as platelets circulating clotting factors are activated which prevents bleeding
and clotting at the same time inside the uterus. Therefore, if the uterine hemostatic factors
are decreased in function due to decreased blood vessel constriction, the type 1
plasminogen activator inhibitor and systemic coagulation factors are also decreased
therefore bleeding is also a symptom of impending uterine atony. A decreased type 1
plasminogen activator inhibitor also decreases platelet count and coagulation factors, an
impending symptom of possible bleeding. The client had a blood loss of >500 ml due to
uterine atony, which later on lead to anemia on the client in relation to decreased

hemoglobin. Early post partum hemorrhage can lead to increased heart rate as a
compensatory mechanism of the body with the decreased blood pressure or hypotension.
Skin turns pallor in color and characteristic due to blood loss and fluid volume deficit. An
acute blood loss can also lead to decreased blood flow to the uterine wall and myometrial
fibers. As a result, uterine atony happens.
2. Synthesis of the disease
a) Definition of disease
Uterine Atony is the relaxation of the uterus when it failed to contract that will
eventually lead to hemorrhage, Pillitteri (2014). An overstretch or overpressure on the
fundus or myometrium can triggers risk for uterine atony. Once the myometrium fails to
contract, palpating the uterus would indicate a “soft and boggy” uterus leading to uterine
atony. If the myometrium fails to contract, there would be a decreased constriction of
blood vessels that supplies the placental bed which results to vaginal bleeding due to the
placental implantation site that does not able to contract and constrict. The uterine
hemostatic function is also termed as the “uterine healing” will decrease its function.
Therefore, if the uterine hemostatic factors are decreased in function due to decreased
blood vessel constriction, the type 1 plasminogen activator inhibitor and systemic
coagulation factors are also decreased then bleeding is also a symptom of impending
uterine atony. A decreased type 1 plasminogen activator inhibitor also decreases platelet
count and coagulation factors, an impending symptom of possible bleeding. The
symptoms of uterine atony include: excessive and uncontrolled bleeding following the

birth of the infant, decreased blood pressure, an increased heart rate, weakness, anemia
b) Predisposing Factors/ Precipitating Factors with rationale
There are several factors that may prevent the muscles of the uterus from contracting
after labor, these includes: multiple gestation, polyhydramnios (excessive amount of
amniotic fluid), a large baby/LGA (>9lb), the presence of uterine myomas. These are the
conditions that distend the uterus beyond average capacity that’s why excessive bleeding
occurs. An operative birth and a precipitous birth are the conditions that could have
caused cervical or uterine lacerations that may also lead to uterine atony while placenta
previa, placenta accreta, premature separation of the placenta, and retained placental
fragments are conditions with varied placental site or attachment leads to bleeding. Deep
anesthesia, high parity or ↑ maternal age, and prolonged labor are also the conditions that
leave the uterus unable to contract readily thus may lead to hemorrhage or uterine atony.
c) Signs and symptoms with rationale noting the specific dates for the occurrence of
each manifestation
Upon the assessment, the client gave birth on the 24th day of February year 2020 and
experienced excessive bleeding right after the delivery. She was monitored and
immediately transferred to another hospital on the 25th because signs and symptoms of
uterine atony was already seen with the client. She experienced rapid heart rate,

hypotension, body weakness, and skin pallor. Increased heart rate due to the excessive
blood loss as a compensatory mechanism of the body with decreased blood pressure or
hypotension. Body weakness due to the decreased blood supply in her body. And lastly,
skin turns pallor in color and characteristics due to blood loss and fluid volume deficit.
I. The Patient and Their Care
1. Nursing Management

2. NCP


ACTUAL FDAR
Name: Shiela Manalo Birthday: January 28, 2002 Age: 18 Sex: Female
CS: Single
Address: Sto. Niño, San Fernando Pampanga Ward: OB Ward 105 (High Risk)
Bill No.:643603
NURSES PROGRESS NOTES
DATE TIME FOCUS NURSES PROGRESS NOTES

February 6:00am Acute Pain D: Received patient sitting on bed with
25, 2020 facial grimaces
>Verbalized “sumasakit pa yung
pwerta ko”
>With a pain scale of 8/10
>Initial vital signs as follow : T: 35
degrees celcius BP: 90/60mmHg PR:
91bpm RR: 20cpm
6:00am A: Established rapport
>Monitored vital signs
>Encouraged deep breathing exercise
>Change the patients position q2
>Provided diversional activities such
as socializing with the patient
>Encouraged early ambulation
8:00am Doctor’s Rounds Seen on rounds by Dr. Dabu with
orders made and carried out
>Possible MGH
>Home Meds:
1. Cefuroxime 500mg/cap q12x7 days
2. Ferrous Sulfate 1tab OD x 3 months
3. Calcium Carbonate 1tab BID x 3
months
OPD follow up: March 4, 2020, Room
12, 1:00pm
11:00am R: Pain scale of 3/10
IX. PATIENT’S DAILY PROGRESS IN THE HOSPITAL

ADMISSION
DAY 2 Discharge
February 25, 2020
February 26, 2020 February 27, 2020
(10:25 am)
NURSING HOLY ANGEL
10:25am - Vaginal Risk UNIVERSITY
for blood For home41 maintenance
PROBLEMS: Bleeding transfusion reaction and management
11:30am -
Risk for blood
transfusion reaction
VITAL 8am 8am 8am
SIGNS 36.7̊ C 36.9̊ C 37̊ C
TEMP 83 bpm 86 bpm 91 bpm
PR 20 bpm 20 bpm 20 bpm
RR 100/60mmHg 90/60mmHg 90/60mmHg
BP
12nn 12nn 12nn
36.6̊ C 36.8̊ C 35.4̊ C
84 bpm 86 pbm 70 bpm
20 bpm 21 bpm 22 bpm
100/60mmHg 90/60mmHg 110/80mmHg
DIAGNOSTI Complete Blood Complete Blood Count N/A
C AND Count
LABORATO Immunology/Serology
RY
PROCEDUR
E
MEDICAL IVF: IVF: IVF:

MANAGEM #1 D5LRS 1L + 20 #2 PNSS 1L x KVO #3 PNSS 1L x KVO
ENT units Oxytocin 5 units of PRBC Drugs:
1. CONTRA 20gtts/min Start Consumed Cefuroxime 500mg 1
PTIONS 5 units of PRBC #3 2:30am 7:00am tab BID
(IVF, 02, Start Consumed #4 9:10pm 12am Calcium Carbonate 1 tab
INHALATIO #1 12:10pm 4:30pm Drugs: BID
N, FOLEY #2 8pm 1:00am Cefuroxime 500mg 1 tab Ferrous Sulfate 1 tab
CATHETER, Drugs: BID OD
NGT, ETC,) Methergine
School1 of
ampule Calcium
Nursing Carbonate
and Allied 1 tab Sciences
Medical Diet: DAT
2. DRUGS IM every 2 hours x 3 BID Activities:N/A

doses Ferrous Sulfate 1 tab OD
3. DIET
Referrals: Medical Management
i. IVF
Nursing
Client’s
responsibilities
Medical General Indications/Purpos Date response
prior, during,
Management Description e ordered of the
and after
treatment
procedure
PNSS x KVO Isotonic This was indicated February Patient did Determine
solution has to the patient as an 25,2020 not have what type of
the same assess for allergic IF to infuse.
concentration medications and to reaction Check the IV
as blood and restore the vascular site for
plasma. Used volume due to the patency.
to restore loss of blood Check for
vascular during delivery IVF’s proper
volumes regulation.
Check for
fluids to flow.
ii. Drugs
Generic General Indications/Purpos Date Client’s Nursing

Name ad Action e ordered response responsibilities
Brand to the (per
Name medication medication)
with actal prior, during,
Dosage, side effects and after
Route, and procedure
Frequency
Ferrous Prevention Ferrous Sulfate is February No allergic Monitor
Sulfate and used to treat iron 25,2020 reaction hemoglobin,
(Ferosol) 1 treatment of deficiency anemia (a hematocrit, and
tab OD iron lack of red blood iron levels.
deficiency cells caused by
anemia having too little iron Inform patient
in the body) to take on an
empty stomach
to increase
absorption and
vitamin c helps
with absorption

Assess
nutritional
status and
bowel function
Advise patient
to take medicine
as prescribed
Cefuroxime Bind to Cefuroxime is used February No allergic Assess patient
(Zinacef) bacterial to treat a wide 25, 2020 reactions for signs and
500 mg 1 tab cell wall variety of bacterial symptoms of
BID membrane, infections. This infection prior
causing cell medication is known to and
death as a cephalosporin throughout
antibiotic. It works therapy.
by stopping the Before starting
growth of bacteria. therapy, collect
This antibiotic treats past medical
only bacterial history to
infections determine past
use of
cephalosporins.
Patients with
negative history
with penicillin
sensitivity
history may still
have allergic
reaction.
Observe patient
for signs and
symptoms of
anaphylaxis.
Discontinue the
drug and notify
physician or
other health
care
professional
immediately if
any symptoms
occur.
Instruct patient
to report signs
of

hypersensitivity.
Inform patient
drug is used to
treat infection.
Calcium To prevent Calcium carbonate is February No allergic Monitor VS
Carbonate transient a dietary supplement 25, 2020 reaction especially BP
(Caltitrol) skeletal loss used when the and PR
associated amount of calcium Obtain ECG
with taken in the diet is results
childbearing not enough. Calcium Assess for
is needed by the heartburn,
body for healthy indigestion, and
bones, muscles, abdominal pain
nervous system, and Monitor serum
heart. Calcium calcium before
carbonate also is treatment
used as an antacid to Assess for
relieve heartburn, nausea and
acid indigestion, and vomiting,
upset stomach. anorexia, thirst,
and severe
constipation
Tell patient that
the drug is used
for treatment of
heartburn and
upset stomach
and prevent low
calcium levels
Advise the
patient the drug
has a metallic
taste
Tell the patient
the possible side
effects she may
feel after taking
the drug such as
upset stomach,
dry mouth,
increased
urination and
loss of appetite

iii. Diet
Type of General Indications/Purpos Date Client’s Nursing

diet Description e ordered response responsibilities
and/or (per
relation medication)
to diet prior, during
initiation of
diet
Diet As Diet as DAT, Diet as February The Teach their
Tolerated tolerated is Tolerated. This 26,2020 patient patients about
usually particular diet is only was proper nutrition
advised in giver when client compliant as it relates to
relation to can now tolerate any to the diet their health.
surgery. food she desires that given to
Once a is nutritious, if this her
surgical will not lead to any
procedure is complications and if
complete, the client needs
individuals further monitoring
are given for lab test.
only liquids,
such as
water. The
diet
progresses
to solid
foods in the
form of
purees,
chunks and
finally a
regular diet.
iv. Activity - N/A
Referral: Surgical Management - N/A
X. HEALTH EDUCATION PLANS
M- Home medications instructed:

* Cefuroxime 500mg/cap q 12 x 7 days
* Ferrous Sulfate 1 tab OD x 3 months
* Calcium Carbonate 1 tab BID x 3 months
E- Walk and ambulate every morning to promote recovery
T- Advised to follow treatment regimen
H- Provided health teachings specifically;
The need to monitor the amount and consistency of vaginal bleeding
Practice daily perineal and body hygiene
Eating nutritious food specifically green leafy vegetables
O- Instructed follow up OPD on March 14,2020 Room #12, 1:00 PM
D- Instructed DAT ( diet as tolerated)
II. CONCLUSION
The patient is a gravida 1 para 1 with a diagnosis of acute blood loss secondary to
early postpartum hemorrhage secondary to transient uterine atony; anemia secondary
corrected status post NSD. She was currently on her fourth bag of packed RBC with an
on-going intravenous fluid bottle number 3, 1 liter x KVO at 750 cc level on her left arm;
and a heplock in her right arm. The patient’s latest vital signs as follows: Temperature:
35.4’c; Pulse rate: 70bpm; Respiratory rate: 22 cpm; Blood pressure: 110/80 mmHg. The
patient’s latest medications are: Cefuroxime 500mg 1 tab BID to be taken at 8 am;
Ferrous Sulfate 1 tab OD to be taken at 6 am; and Calcium Carbonate 1 tab BID to be
taken at 8 am.

The patient’s latest doctor’s orders are as follows:
- Possible MGH
- Home Medications:
1. Cefuroxime 500 mg/cap, 1 cap q12 x 7 days
2. Ferrous Sulfate 1 tab OD x 3 months
3. Calcium Carbonate 1 tab BID x 3 months
- OPD follow up: March 4, 2020 room 12, 1:00 pm
III. LEARNING DERIVED
One thing that the student nurses learned while conducting the case study was
about how surprising cases could be in the hospitals. The moment you walk in the
hospital, already expect that there would be cases that are new and interesting to learn
about. You will see the difference on what was taught on lectures and what it feels like
seeing them actual. The case of the patient that was encountered deepened the passion of
the student nurses in their chosen profession. Patient x was too young to encounter these
kinds of complications, that is why as student nurses, proper health teachings were
provided to prevent the repeat of the incident. Seeing patients with such conditions gave
realizations to the student nurses that complications could occur to patients, no matter
what your age was, or what your situation might be. There are certain conditions that
happens unexpectedly and for that, it is important to be careful and ready always. These
kinds of situations also gave motivation to student nurses to become better nurses
someday. All the learning that were being taught should already all be kept in mind

because these could be of help someday. Besides from the learning that were taught in the
classroom, the student nurses also had learned that everyday was a learning experience in
the hospital. There were a lot of things that you can learn every duty, that were not taught
in classrooms. And those learning do not only include the knowledge you acquire during
patient interaction, but also on the mistakes a student makes. When a student makes
mistakes, he/she would most likely remember it for the rest of his/her life. That is why as
student nurses, accepting mistakes would be one step in learning more in the hospital
setting. It should not be taken negatively, instead it should be taken as something that
would help you to be better. As future nurses, one should not forget the goal of nursing
which is to help individuals to reach an optimum state of well-being. It is very important
to provide those individuals with the best care possible. As what Rawsi Williams had
said, “To do what nobody else will do, a way that nobody else can do in spite of all we go
through; that is to be a NURSE.”

IV. Bibliography APA
American Association for Clinical Chemistry, (2018). Hepatitis B Testing. Retrieved

from https://labtestsonline.org/tests/hepatitis-b-testing
American Association for Clinical Chemistry, (2020). Syphilis test. Retrieved from
https://labtestsonline.org/tests/syphilis-tests
Arrington, D. (n.d). Lymphocytes: Definition, Functions & Types. Retrieved from

https://study.com/academy/lesson/lymphocytes-definition-functions-types.html
Barell, A. (2020). What's to know about hemoglobin levels. Retrieved from

https://www.medicalnewstoday.com/articles/318050
Braga J., et al. (2019). Modified Pereira Suture as an Effective Option to Treat
Postpartum Hemorrhage due to Uterine Atony. Retrieved from https://sci-
hub.tw/10.1055/s-0037-1613690
Fletcher, J. (2018). What to know about RPR testing for syphilis. Retrieved from
Huizen, J. (2020). What are neutrophils and what do they do. Retrieved from
Wormer, K. C., Jamil, R. T., Bryant, S. B., (2019). Acute Postpartum Hemorrhage.
Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499988/
Medline Plus. (2020). Blood typing. Retrieved from

https://medlineplus.gov/ency/article/003345.ht
Moores, D. (2017). Complete Blood Count. Retrieved from

https://www.healthline.com/health/cbc
Shrestha A, Dongol A, Chawla CD, Adhikari R. (2011). Rectal Misoprostol versus

Intramuscular Oxytocin for Prevention of Postpartum Hemorrhage. Retrieved
from https://pdfs.semanticscholar.org/

Surat, P. (2019). Eosinophil Function. Retrieved from https://www.news-

medical.net/life-sciences/Eosinophil-Function.aspx
Vital Statistics Report, (2013). Top Ten Causes of Death, 2011-2013. Retrieved from
https://psa.gov.ph/
World Health Organization (2012). WHO recommendations on prevention and treatment

of postpartum haemorrhage. Retrieved from
https://www.who.int/reproductivehealth/topics/maternal_perinatal

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HOLY ANGEL UNIVERSITY 1

Acute blood loss secondary to early postpartum hemorrhage secondary to

transient uterine atony; anemia secondary corrected status post NSD.

Description of the disease:

According to Wormer, et. al. (2019), postpartum hemorrhage is excessive

baby is delivered, the uterus normally continues to contract (tightening of uterine

School of Nursing and Allied Medical Sciences

Recent trends, innovations, and/or refinements in treatment:

A study from South Africa, entitled Rectal Misoprostol versus Intramuscular

Oxytocin for Prevention of Post Partum Hemorrhage by Shrestha A, Dongol A, Chawla

CD, Adhikari R. (2011), compared a combination of intramuscular syntometrine injection

interventions to control the bleeding.

alternative to conventional utero-tonic agents like Oxytocin in active management of

peripheral centers. It is as effective in prevention of postpartum hemorrhage as

worthy to use rectal misoprostol as an alternative to Oxytocin.

Furthermore, there is a recent study entitled “Modified Pereira Suture as an

School of Nursing and Allied Medical Sciences

sonography revealed a normal uterus with normal uterine artery impedance.

techniques. A blunt, 70 mm semicircular needle, mounted with a Vicryl 1 (polyglactin

and 3–4 cm from the lateral border.

School of Nursing and Allied Medical Sciences

Vicryl 1 were placed around the uterus.

The placement of the sutures involved a series of bites inserted superficially,

Statistics (Local & International)

School of Nursing and Allied Medical Sciences

According to the World Health Organization, postpartum haemorrhage (PPH) is

per 100,000 live births respectively. However, developing countries continue to

experience higher numbers of maternal deaths compared to developed countries.

000 maternal deaths) compared to 16 (2,200 maternal deaths) in developed countries.

Thirty-five countries have been identified as either making insufficient or no progress

School of Nursing and Allied Medical Sciences

Student Centered Objectives:

1. Integration and application of nursing concepts, theories, and actions.

2. Application of the nursing process specifically assessment, diagnosis, formulation

of plan of care, implementation of safe and quality nursing interventions and

evaluation with the patient.

3. Application of evidenced-based practice when providing nursing care and

preventing injury to at-risk/high risk mother and sick child.

4. Ensurance of working relationships with at-risk/high risk patients based on trust,

respect and shared decision making using appropriate

5. Documentation of patient’s response/nursing care services and outcomes of

nursing care rendered.

6. Ensuring the completeness, integrity, safety, accessibility, and security of

7. Adherence to protocol and principles of confidentiality in safekeeping and

8. Collaboration with other members of the health team in the implementation of

programs and services.

9. Maintenance of a positive practice environment.

School of Nursing and Allied Medical Sciences

11. Customizing nursing interventions based on Philippine culture and values.

Patient Centered Objectives:

At the end of the study, the patient would be able to:

1. Accept and welcome student nurses from Holy Angel University

2. Establish rapport with the student nurses

3. Participate in assessment phase

4. Verbalize willingness to participate in nursing interventions provided by the

5. Cooperate with student nurses with ease and comfort

6. Participate in implementation phase

appropriate for his/her condition