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College of Nursing

Postpartum Hemorrhage Secondary to

Retained Placenta

Presented by:

II - A / SECTION 1 / GROUP # 4

ALVAREZ, CELINE KYLE M.

CALIPAY, JADE FLORIDEL L.
FODRA, MYKA J.
LAGUD, MILYN F.
PANGILINAN, RONA MAE P.

Presented to:

Ms. Ariane Joy S. Cantilero, RM, RMT

Ms. Varhielyn M. Escalante, RM, BSM
Ms. Maria Khristina C. Huerto, RM, BSM
Ms. Joymie F. Matreo, RM, LPT
Ms. Kcllyn Joy O. Separa, RM, BSM©
Ms. Maria Judith Tugado, RM , BSM©
Clinical Instructors

Date:

FEBRUARY 2023

In Partial Fulfillment of the Requirement in MDWY 90 for the Diploma in Midwifery

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 ACKNOWLEDGEMENT

This case study would not have been possible without the participation and

collaboration of numerous people, some of whose names may or may not have been

made public. We sincerely recognize and value the efforts they made. We would like

to express our gratitude in particular of the following:

To all of our Clinical Instructors, Ms. Ariane Joy S. Cantilero, RM, RMT, Ms.

Varhielyn M. Escalante, RM, BSM, Ms. Maria Khristina C. Huerto, RM, BSM, Ms.

Joymie F. Matreo, RM, LPT, Ms. Kcllyn Joy O. Separa, RM, BSM©, Ms. Maria Judith

Tugado, RM, BSM© for the patience, effort and time extended checking the draft,

sharing suggestions and constructive criticisms which meant so much for the

completion of this study.

To our Family and Friends, thank you for your unconditional love, support and

patience. For continuously understanding and believing in us. Your constant support

serves as our inspiration and motivation to finish this study.

To Client FSM, who is the participant of this study. For being cooperative and

approachable throughout the study, for taking the time to answer all of the questions

with honesty.

Above all, Thanks to the Great Almighty. The provider of all wisdom and

understanding for his unending love. Thank you

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 TABLE OF CONTENTS

INTRODUCTION 5
I. DEMOGRAPHIC DATA 7
II. REASON FOR SEEKING HEALTH CARE 7
III. HISTORY OF PRESENT ILLNESS 7
IV. PAST MEDICAL HISTORY 8
V. OBSTETRIC-GYNECOLOGICAL HISTORY 9
VI. HEREDO-FAMILIAL HISTORY 10
A. Genogram 10
B. FAMILY APGAR 11
VII. DEVELOPMENTAL HISTORY 12
VIII. GORDON’S 11 FUNCTIONAL HEALTH PATTERNS 13
A. Health Perception – Health Management 13
B. Nutritional – Metabolic 14
C. Elimination 15
D. Activity – Exercise 15
E. Sleep – Rest 17
F. Cognitive – Perceptual 18
G. Self-Perception – Self-Concept 18
H. Role-Relationship 19
I. Sexuality – Reproductive 20
J. Coping-Stress 20
K. Value-Belief 20
IX. COMPREHENSIVE PHYSICAL EXAMINATION 21
A. Vital Signs 21
B. Anthropometric Data 21
C. General Appearance 21
D. Focused Assessment 23
X. Diagnostic Test 24
A. Non-Invasive 24
XI. Pathophysiology 26
A. Anatomy 27
CLIENT-BASED (only those facts related to the case are included) 28
XII. CASE MANAGEMENT 29
A. Drug Study 29
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XII. Nursing Management 30
IV. Listing of Nursing Problems 30
I. Postpartum Hemorrhage 30
II. Perineal Laceration Error! Bookmark not defined.
III. Diet Error! Bookmark not defined.
V. Prioritization of Nursing Problems 30
XIII. Plans for Nursing Action 34
A. Health Care Plan 34
XIV. DISCHARGE PLAN 40
XV. RECOMMENDATION 41
PAMPHLET (English) 42
PAMPHLET (Tagalog) 43

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1 INTRODUCTION

Postpartum hemorrhage (also called PPH) is a serious condition when a woman

experience heavy bleeding after giving birth. About 1 to 5 in 100 women who have a

baby (1 to 5 percent) have experienced PPH. After your baby is delivered, the uterus

normally contracts to push out the placenta, the contractions help put pressure on

bleeding vessels where the placenta was attached in your uterus. If the contractions

are not strong enough, the vessels bleed more. It can also happen if small pieces of

the placenta stay attached or also called retained placenta. This happens if the

placenta did not deliver within 30 to 60 minutes after you give birth. Even if you pass

the placenta soon after birth, your provider checks the placenta to make sure the

cotyledons is complete. If a placental fragment is not removed from the uterus right

away, it may cause bleeding. Active management of the third stage of labor should be

used routinely to reduce this kind of complication. Use of oxytocin after delivery is the

most important and effective component of this practice. Oxytocin is more effective

than misoprostol for prevention and treatment of uterine atony and has fewer adverse

effects. Appropriate management of postpartum hemorrhage requires prompt

diagnosis and treatment. The Four T's mnemonic can be used to identify and address

the four most common causes of postpartum hemorrhage (Uterine Atony [Tone];

Laceration, Hematoma, Inversion, Rupture [Trauma]; Retained Tissue or Invasive

Placenta [Tissue]; and Coagulopathy [Thrombin]).

Postpartum hemorrhage (PPH) remains as the leading cause of maternal morbidity

and mortality worldwide. It accounts for 13% maternal deaths in developed countries

and 28% of maternal deaths in developing countries, further disproportionately

affecting those in the world’s poorest countries. While avoidable, the Philippines is still

among the countries with high maternal deaths. In 2015, 114 deaths per 100,000 live

5
births were registered in the country – a far cry from the target of 52 deaths per 100,000

live births of these deaths, 30% were reportedly associated with PPH.

The major causes of postpartum hemorrhage are uterine atony, lacerations,

retained placenta or clots, and clotting factor deficiency. Uterine massage, oxytocin,

and methylergonovine are the main treatments, along with blood transfusion and

cardiovascular support.

Retained placenta complicates 2-3% of vaginal deliveries and is a known cause of

postpartum hemorrhage. Retained placenta is when the placenta doesn’t completely

come out of the uterus after the baby is born. Sometimes, a piece of the placenta is

left behind in the uterus (womb). Retained placenta can lead to severe infection or life-

threatening blood loss for the mother. The Reasons why they experience retained

placenta is because the contractions aren’t strong enough to expel it, the placenta is

unusually strongly attached to the wall of the uterus, The Mother have placenta accreta

(when the placenta implants too deeply into the wall of the uterus), and the cervix

closes and traps the placenta inside the uterus.

As we conduct the study, we will learn more about the causes, symptoms, and

treatments of postpartum hemorrhage and will share this information with the public.

We chose this study because this will give awareness not only to us but also to the

people who will be reading this in the future. The case study of postpartum hemorrhage

will help not only us but also the public to understand the risk factors and danger of

this complication. Everyone, not only pregnant women will be educated with this study.

People will be more open about the importance of prenatal check-up.

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 I. DEMOGRAPHIC DATA
A. Initials of Clients’ Name: F S M Date of Admission: Nov. 28,2022
B. Address: General Trias Cavite Time of Admission: 3:00 PM
C. Age: 36 y.o Date of Interview: Jan. 12, 2023
D. Birth Date: September 10, 1986 Primary Informant: Client FSM
E. Birth Place: Manila Secondary Informant: Mother
F. Sex: Female Other Data Sources: Laboratory
G. Civil Status: Married Result & Doctor’s Findings
H. Religion: Catholic
I. Highest Educational Attainment: College Undergraduate
J. Occupation: Customer Service Representative
K. Monthly Income / Budget : 30,000

Daily Consumption Monthly Expenses Per Day Expenses

Electricity 4,000/month ÷ 30 133
Water 500/month ÷ 30 17
Internet/ Load 2,000/month ÷ 30 67
Grocery 5,000/month ÷ 30 167
Food 10,000/month ÷ 30 333
LPG 800/month ÷ 30 27
Transportation 1,000/month ÷ 30 33
Total: 777
Table 1. Family Daily Expenses of client F.S.M.

II. REASON FOR SEEKING HEALTH CARE

Client FSM was admitted at ERS Maternity and Pediatric Clinic last November

28,2022 as she is experiencing labor pains, Client FSM later on delivered to an alive

baby boy at 1:15 AM, November 29, 2022, as the physician was having a hard time

getting the placenta, the client experience blood loss estimating to 600cc according to

the Staff Midwife. The placenta was out at 2:00 AM but there are some retained

placenta so at 2:30 AM the client was transferred to a hospital due to Retained

Placenta v. focal Placenta Accreta for Postpartum curettage.

III. HISTORY OF PRESENT ILLNESS

Last November 29, 2022 at ERS Maternity and Pediatric Care Clinic, Client FSM

was attended by a Physician on her childbirth. She was later on diagnosed by the

Physician with Placenta Accreta after having a hard time removing her placenta that

lasted for an hour. The client’s diaper was soaked with blood with an estimated blood

7
loss of 600cc. Upon checking, her blood pressure was at 100/70mmHg from

110/80mmHg upon delivering the baby. During the procedure the Physician ordered

the Attending Midwife to refer the client to the Hospital. The reason for referral is

retained placenta v. focal Placenta Accreta for postpartum curettage or possible

hysterectomy.

During the home visit assessment, the client mentioned that after she got

discharged from the hospital, she felt pain in her perineum and experienced bleeding.

Client FSM showed her laboratory and medical results on December 7, 2022. Client

FSM went to her doctor for postpartum checkup and based on her examination, the

uterus is enlarged in size and inverted measures of 10.0 x 8.6 x 8.9cm. Upper segment

1.0 cm lower segment 1.8 cm considered for retained product of conception. The

Doctor gave methergine tablets good for 7 days and after 3 days, her bleeding finally

stops.

2 IV. PAST MEDICAL HISTORY

The client does not have any past illnesses from when she was a child up until

adulthood. She says that she has no allergies to any kinds of foods, drinks and

medication. As stated by the client’s mother, client FSM has had the following vaccines

from her childhood: BCG, Hepatitis B, MMR and OPV. During her fifth pregnancy, her

doctor prescribed her purple tablets or Methergine tablets to help her postpartum

bleeding to stop, Sangobion for her iron supply and Malunggay capsules to help her in

breastmilk production. Client FSM stated that she was fully immunized by tetanus

toxoid as well as COVID vaccine with no booster.

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3 V. OBSTETRIC-GYNECOLOGICAL HISTORY

The client had her menarche when she was 10 years old. Client has a regular

menstrual cycle, her menstruation usually lasted for 4-5 days, she used 3-4 pads a day

with moderate flow. The Client’s OB Score is G5P5 (5005). The client had her first born

on May 25, 2005 (Male) at Ospital ng Sampaloc, Manila. The second child was also

born at Ospital ng Sampaloc, Manila on May 15, 2006 who is also a male. The third

and fourth child was both born at ERS Maternity & Pediatric Care Clinic on September

20, 2014 (Female) and May 13, 2018 (Male). There are no complications in the delivery

of the Client on all four pregnancies. Lastly the fifth born (Male) was also born at ERS

Maternity & Pediatric Care Clinic last November 29, 2022.

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4 VI. HEREDO-FAMILIAL HISTORY

A. GENOGRAM

Figure 1. Genogram of Client FSM

The Figure shows the Genogram of Client’s FSM Family starting from her Grandparents up to her generation. The Genogram shows that

there are no illnesses in her family except for one. Her Grandfather from Father side has diabetes, other than that all her f amily members is still

alive and well. There is no significant illness on the genogram that can be a factor on the client’s complication, she is the first one who experience

this in the Family.

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 B. FAMILY APGAR
Constructs Questions Almost Some of Hardy
Always the Time Ever
(2) (1) (0)
Adaptation I am satisfied with the help that I 2
receive from my family when
something is troubling me.
Partnership I am satisfied with the way my 2
family discusses items of
common interest and shares
problem-solving with me
Growth I find that my family accepts my 1
wishes to take on new activities
or make changes in my lifestyle.
Affection I am satisfied with the way my 2
family expresses affection and
responds to my feelings such as
anger, sorrow and love.
Resolve I am satisfied with the way my 2
family and I spend time together.
TOTAL 9
Table 2. Family APGAR of client F.S.M

Table 2 shows the family APGAR score sheet of client F.S.M, A total score of

9 points indicates that Client's F.S.M has a high functioning family. The client always

receives full support from her family, when dealing with any kind of hardship her family

is always at her back no matter what happens. The client and her family have open

communication to settle things. Even small talk will give her a sense of hope and inner

strength to fight problems. If the client wants to try specific hobbies or specific activities,

she asks for her family suggestions if it is good to try or not. The client makes sure that

her family will allow her to do those things. The client also stated that her family is

loving and caring. Client also added she loves the way her family finds time to have

quality time together. The client and her family have a good and harmonious

relationship.

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5 VII. DEVELOPMENTAL HISTORY

Erik Erickson’s Psychosocial Development

Stages Specific Task(s) Age Evidence of Milestone Achievement
Trust vs. Mistrust
In the first stage, a child The client’s mother stated that when client FSM
Infancy
develops their sense of was still a child, she felt safe and secure in her
1 (0 to 18
trust to carry them into environment because she has a good bond with
months)
relationships and feel her family as well as other relatives.
secure.
Autonomy vs. Shame
and Doubt
On the second stage, a Client FSM’s mother stated that when she was
child is encouraged in Toddler a toddler growing up, she taught her to be
2 their increase of (2 to 3 independent by letting her eat by herself as well
independence to be years old) as letting her walk by herself. Her mother
more confident and encouraged her by acknowledging her efforts.
secure on their own
ability to survive.
During this time, the client started going to
school at around 4 or 5 years old. She says that
she was very shy and scared at first because
she was left by her mother at school. But as
Initiative vs. Guilt time goes by, she says that she was able to feel
Preschool
The third stage involves comfortable thanks to her nice friends and
3 (3 to 5
the child interacting with classmates at school. That is why she was able
years old)
other children. to adjust to her new environment. At this stage,
the client says that she enjoys being with
people her age group and that she feels great
when her teachers and parents acknowledge
her efforts at school.
Industry vs. Inferiority
At this stage, the child The client was more aware of having
School-
feels the need of competition inside the classroom so she was
age
4 approval from the encouraged more to excel more at school and
(6 to 11
society and begins to she was receiving encouragement from her
years old)
develop a sense of pride parents and teachers.
in accomplishments.
Identity vs. Role
Confusion During adolescence, the client knows where
The fifth stage is where she excels. She is aware of her strengths and
Adolescen
the child has to learn weaknesses. She tries to explore more on her
ce
5 certain roles they will be hobbies and abilities and she thinks that she still
(12 to 18
occupying as an adult as needs to improve in a lot of things. She says
years old)
well as the changes of that she wants to work abroad if she is given the
the body image as an chance. She was willing to try something new.
adolescent.
Intimacy vs. Isolation The client is in her 20’s and is now curious
On the last stage, they about having an intimate relationship with
begin to share more of others. While being in a relationship makes the
Young/
themselves more client realize that being in a relationship with
Early
intimately to others. And someone makes you realize that
6 adulthood
successful completion communication is really the most important
(19 to 40
on this stage may result thing while having a relationship with someone.
years old)
into happy relationships While having a relationship with someone, you
as well as having sense will be able to share parts of yourself to other
of commitment. people.
Table 3. Developmental History of Client F.S.M. using Erik Erikson’s Psychosocial
Development.

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 The model used to determine the developmental history of the client was Erik

Erikson’s Psychosocial Development Theory. Table number 3 shows the milestones

of the client from infancy up to her ongoing adulthood. During infancy, the client’s

mother stated that she has a good bond with her family because the client was letting

the people around her gain her trust. As the client went to preschool, her mother stated

that client FSM thought that being with people the same age as her has given her

confidence in doing what she loved. Growing up, client FSM was encouraged to do

things independently according to her accord. She was able to explore and develop

intimate relationships with other people. Client FSM stated that she was happy and

contented with the relationships she had with her family and friends.

6 VIII. GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

Marjorie Gordon's 11 Functional Health Pattern Model was used to interview

Client FSM. Through this model, the client was able to express, reveal and emphasize

her past and current health state as well as her health management.

A. HEALTH PERCEPTION – HEALTH MANAGEMENT

Client FSM stated that ever since she was a child, she was taught to believe

that medicine intake and going to the doctor for checkups are the cure for illnesses.

So when she got pregnant from her first up until her fifth child, she was always checked

by an Obstetrician. She feels at ease when she is being checked by a licensed

physician. The client also stated that she is trying her best to eat healthily because she

is now conscious of her health condition. She stated that having good health can lower

the risk of getting ill. The client wants her family to value health because it may affect

their daily lives.

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 B. NUTRITIONAL – METABOLIC
Aside from the medications prescribed by the doctor, client FSM does not take

any other multivitamins as of now. The client consumes about 2,000-2,200ml of fluid

daily. According to the client, she prefers rice more than bread but now, she tries to

lessen her intake of rice since she doesn’t want to gain weight that much. Table 4

shows the 3-day diet recall that was created with the client during the interview.

*3-day Diet Recall

MEALS January 10, 2023 January 11, 2023 January 12, 2023
(TUESDAY) (WEDNESDAY) (THURSDAY)
Breakfast (7:30 1 serving of pancit bihon 4 pcs of pan de sal (480 1 cup of rice (200 kCal)
am) (100 kCal) kCal) 2 pcs. of longganisa
2 slices of wheat loaf 3 tsp. of butter (135 kCal) (244kCal)
bread (100 kcal) 2 glasses of water 3 strips of bacon (135
1 cup of coffee with ½ 1 cup of coffee with ½ tsp kCal)
tsp of sugar and milk (60 of sugar and milk (60 kCal) 1 cup of coffee with ½ tsp
kCal) 1 cup of taho w/ syrup & of sugar and milk (60
2 glasses of water sago (80kCal) kCal)
2 glasses of water
Snacks 1 whole sliced apple (40 2 pc. of ensaymada (200 2 pcs. of sliced wheat loaf
(10:30am) kCal) kCal) bread (100 kCal)
1 ½ pc. of boiled corn 2 glasses of water 2 tsps. of peanut butter
(150 kCal) 1 tetra brick of orange (45 kCal)
2 glasses of water juice (140 kCal) 2 glasses of water
Lunch 1 cup of rice (200 kCal) 2 cups of rice (400 kCal) 2 cup of rice (400 kCal)
(12:30pm) 2 pcs. of hotdog (244 2 pcs. of fried chicken 2 slices of fried porkchop
kCal) wings (172 kCal) (172 kCal)
1 pc. of chicken nugget 2 glasses of water 2 glasses of water
(86 kCal) 1 bottle 290ml soft drink 1 bottle 290ml soft drink
2 glasses of water (100kCal) (100kCal)
Snacks (3:30pm) 2 pcs. of egg sandwich 1 slice of sponge cake (100 2 slices of wheat loaf
(445 kCal) kCal) bread (100 kCal)
1 cup of coffee with ½ 1 pc. of ensaymada (100 2 tsp. of peanut butter
tsp of sugar and milk (60 kCal) spread (45kCal)
kCal) 1 cup of coffee with ½ tsp 2 glasses of water
5 pcs. pastillas candy of sugar and milk (60 kCal)
(100 kCal) 2 glasses of water
2 glasses of water
Dinner (8pm) 2 cups of rice (400 kCal) 1 cup of rice (200 kCal) 1 cup of rice (200 kCal)
2 slices of beef caldereta 1 serving of noodles with 1 slice of pork pata
(344 kCal) egg (186 kCal) (86kCal)
2 glasses of water 2 glasses of water 2 pcs. of baby potatoes
1 whole avocado w/ 2 (276 kCal)
tsps. of condensed milk 2 glasses of water
(65 kCal)
Snacks 1 cup of coffee with ½ 1 cup of coffee with ½ tsp 1 cup of coffee with ½ tsp
(10:30pm) tsp of sugar and milk (60 of sugar and milk (60 kCal) of sugar and milk (60
kCal) 2 glasses of water kCal)
8 pcs. of pastillas candy 1 pack of chocolate 2 glasses of water
(160 kCal) sandwich crackers (150 1 pack of strawberry
2 glasses of water kCal) sandwich crackers (150
kCal)
Total Calorie 2,549 kCal 2, 688 kCal 2,373 kCal
Intake
Total Fluid Intake 2,200ml 2,200ml 2,200ml
Table4. 3-Day Diet Recall of Client F.S.M.

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 Table 4 shows the 3-Day diet recall of Client FSM. On January 10, 2023, she had

a total of 2,549 kCal intake. On the next day, January 11, 2023, she consumed 2,688

kCal intake. And on January 12, 2023, she had a 2,373 kCal intake. The Client’s meals

on January 10 and 11 succeeds the needed calorie intake by her body as a Lactating

Mother which is 2,339 kCal intake per day.

C. ELIMINATION

According to the client she has a normal daily bowel movement, it is usually

dark brown in color. She also stated that she experienced discomfort during elimination

because of the stitches she had. Furthermore, the client also stated that during day

time she usually urinates for about five times or more, and the urine color is usually

yellow.

6.1 D. ACTIVITY – EXERCISE

Client FSM has been observed before, during and after the course of the

interview. It has been observed that the client:

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*7-Day Activity Table

Table 5. 7-Day Activity Table of Client F.S.M.

Client FSM's 7-Day Activity Table is displayed. The table shows that the client

was able to sleep early at night and woke up early the following day but in the middle

of her sleep she would get up to babysit and feed her baby. She typically starts her

day by cooking meals for her family. She would also clean the house or take a bath

after eating. She has 1-3 hours of rest and time for errands every afternoon, in between

those times she would also babysit her baby. She would prepare dinner after cleaning

the house. The Client is currently on maternity leave so there was no work reported in

this activity table.

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 *Katz Index of Independence in Activities of Daily Living
Activities Independence = 1 point Dependence = 0 point
Points (1 or 0) No supervision, direction or With supervision, direction or
personal assistance needed personal assistance or total
care
Bathing 1
Dressing 1
Toileting 1
Transferring 1
Continence 1
Feeding 1
TOTAL: 6
Table 6. Katz Index of Independence in Activities of Daily Living of Client F.S.M.

Table 6 displays the Katz Index of Independence in Daily Living Activities of

Client FSM. The client scored a perfect 6, which is interpreted as, the client has the full

capability to function on her own without any supervision, direction, or assistance from

other people in the indicated activities, which are bathing, dressing, toileting,

transferring, continence, and feeding.

6.2 E. SLEEP – REST

*7-Day Sleep Diary

Constructs Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

Jan. 9 Jan. Jan. 11 Jan. 12 Jan. 13 Jan. 14 Jan. 15
Mon. 10 Wed. Thurs. Fri. Sat. Sun.
Tues.
Hours of 6 6 5 6 7 6 4
Sleep
Sleeping 9 PM 9 PM 9 PM 9 PM 9 PM 9 PM 10 PM
Time
Waking 5 AM 6 AM 5 AM 5 AM 6 AM 5 AM 5 AM
Time
Bedtime Watchi Movies Videos Reading Watching Watching Reading
Rituals ng Videos Videos
Movies
Feeling Refres Feeling Feeling Refresh Energetic Feeling Feeling
upon hed Tired Tired ed Tired Tired
waking up
Problem Babysi Babysit Babysitti Babysitti Babysittin Babysittin Babysitti
Encountere tting ting ng ng g g ng
d
Table7. 7-Day Sleep Diary of Client F.S.M.

17
 Table 7 displays Client FSM's 7-Day Sleep Diary. The table shows the client

does not have sufficient sleep for all seven days because she is taking care of her 1-

month-old baby, her sleep ranges from 4 to 7 hours. The table shows that the client

usually sleeps before 9 pm and wakes up early because she needs to prepare food for

her family. It is also indicated that the client encountered a problem while sleeping

which is when she babysits and feeds her baby. She usually wakes up feeling tired

and refreshed but there are also days where she feels energetic.

6.3 F. COGNITIVE – PERCEPTUAL

During the interview process, client F.S.M was assessed as attentive and

oriented. She had a good memory for remembering her past events. However, she

experiences difficulty in making decisions, especially on important matters. The client

also stated that she did not experience any form of discomfort throughout the interview

and assessment.

6.4 G. SELF-PERCEPTION – SELF-CONCEPT

Client F.S.M perceives herself as someone who’s always exhausted and sleep

deprived. She also stated that almost everything, she can't sleep properly and timely.

However, despite having these feelings and perceptions towards herself, she stated

that she does not lose hope, and that she always tries hard to stay optimistic and finds

a way to have a proper rest and time to herself

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6.5 H. ROLE-RELATIONSHIP
*Ecomap

Figure 2. Ecomap of Client F.S.M.

Upon interview, the client stated that she has a relationship with her husband for more than decades. As a mom of 5 children, the client

stated that she really makes sure that she can provide the needs of her children. As a wife, the client stated that she and her husband work hand

in hand in guiding their children and provide the needs for their children. As a wife she can provide the needs of her husband by having quality

time and good communication. The client stated that having her own family is not an excuse to leave or ignore the parents. As a child, she always

took care of her parents by supporting them financially, emotionally and physically. The client stated also that she always prioritizes the health of

her parents too. The client as a child has good manners to her parents and has a pure heart in her parents. Client FSM and her in-laws have a

good relationship. Because they have good communication, love, and patience with each other The client has good manners and always respects

her in-laws.
19
I. SEXUALITY – REPRODUCTIVE
Client FSM stated that they have been Married for a long time now, despite that

they still make sure to have time for each other especially during this time where both

of them are home. Client also stated that upon giving birth up to the time of the

interview they haven’t engaged in any sexual activity because of her stiches, The Client

politely refused the questions with regards to what she feels before, during and after

the intercourse, she said that this type of information is confidential for her. She has

now five children and is planning to use Ligation as her Family planning method.

6.6 J. COPING-STRESS

Client FSM stated that after she was diagnosed with Placenta Accreta she

began to wonder what is the reason behind it. She claims that she has an open-

relationship with her family, especially with her supportive husband who always makes

her laugh and helps her to endure everything. She also stated that her work from home

set-up is more appropriate for her as she can get along with her kids more and be a

mother to them.

K. VALUE-BELIEF

Client FSM is a Roman Catholic, as she stated that ever since as a kid, she is a

religious type as her family somehow serve at catholic churches before. When the

pandemic started, they didn't visit churches as often as before due to COVID-19. She

values her family as she grew up in a Filipino cultured family, she also stated that all

her life only revolves on her family and work.

20
7 IX. COMPREHENSIVE PHYSICAL EXAMINATION

A. VITAL SIGNS
T = 36.2OC Date / Time of Exam: 01/12/23

PR = 71 bpm

RR = 19 cpm

BP = 110/80 mmHg

Pain

Client FSM did not experience any sign and symptoms regarding any

complications about her placenta, she is not even well informed that she is considered

as high-risk pregnant due to multiparity and maternal age as the client stated. She is

advised to have a complete bed rest and eat healthy foods rich in iron.

According to the client, on a pain scale of 1-10, 10 being the highest, she

experienced an average kind of pain and rate 7/10. After her surgery she feels numb

because of the epidural anesthesia, but right after it started to ache but is tolerable for

her. She also stated that she is just too tired from the delivery and the surgery that’s

why

B. ANTHROPOMETRIC DATA
Height = 149.86cm BMI = 29.4 (Overweight)

Weight = 66kgs. IBW = 46kgs.

C. GENERAL APPEARANCE

Client FSM weighs 66 kgs. and 149.86 in height, as shown by her 29.4 Body

Mass Index. The client's weight is not proportion for her height, her body is not

proportionate and have a slightly bad posture. Her feet and legs are normal as she

walks toward us as we observed during our interview. Client FSM is very conscious

about herself, especially when the pandemic starts, she usually takes a bath twice a

21
day if she goes outside for the day and once if she just stays at home. She said she

doesn't need to worry about her looks as she is a mother of her five children now, but

she looks neat and clean. She uses tawas as her natural deodorant because it doesn’t

harm the skin and more comfortable with it. She brushes her teeth twice to thrice a day

and also uses mouthwash and sometimes floss her teeth. Generally, the patient's

cleanliness and grooming were decent and presentable.

There are no indications that the patient will cover the facts about her condition

from others. Even though she occasionally, but not always, forgets things or events,

she was in good mental health and wasn't very disturbed by it because it was only

minor things that weren't a huge concern, like turning out the lights and closing the

door. She also responded to essential concerns.

The client provides thorough responses to the inquiries. She is a good example

of a true Filipino citizen as she smiles and welcomes us as we conduct the interview.

The entire interview, she conducts herself politely and gives us respect. She also

responds nicely to our inquiries. As she shared her journey, she spoke smoothly

throughout the interview and conveyed her ideas as if she were telling a story,

demonstrating that she is at ease discussing those topics. She articulated her ideas in

an intelligible, well-organized, and pertinent manner. She also offers some stories,

particularly those pertaining to her family and their history.

22
 D. FOCUSED ASSESSMENT
Body Part Examined Actual Finding Normal Finding Clinical Significance

INTEGUMENTARY SKIN I: Skin is in uniform color, Increased melanin

I: Skin has a slight unblemished, no greater than a person’s
SKIN discoloration on neck, presence of any lesions genetic norm caused by
I: color, armpit, No presence of and edema, no foul odor. pregnancy
uniformity, edema, Lesions and Edema and (BATES, Pocket Guide
lesions no foul odor. P: Skin is smooth, dry, to Physical
P: Skin is smooth, warm to warm to touch, has good Examination, page 86)
P: moisture, temp., touch and has good skin turgor and mobile.
turgor elasticity and turgor.

BREAST AND BREAST AND AXILLAE I: round shape, slightly Both the nipple and the
AXILLAE unequal in size; generally areola are well supplied
I:Breasts are equal in size, symmetric. Skin uniform with smooth muscle
I: breast for size, everted, and rounded. The that contracts to
in color; smooth and
symmetry, contour or color is uniform to the express milk from the
shape, discoloration, intact; striae, moles and
other parts, smooth and nevi. no retractions, no ductal system during
retraction, hyper- intact. There is no swelling breast-feeding. (BATES,
vascularity, swelling, swelling, no edema
or edema present. Pocket Guide to
edema present Physical Examination,
: Areola is symmetrical, : round or oval, color page 299)
: areola for size, shape,
rounded, dark brown in
symmetry, color, varies from light pink to
color. Does not have any
surface characteristics, dark brown, irregular
masses or lesions.
masses, lesions placement of sebaceous
: The nipples are small, glands on the surface of
: nipples for size, shape,
rounded, and inverted. the areola.
position, color,
discharge, lesion Both points in the same
direction and does have : round, everted, and
P: lymph nodes, breast, discharge (Breastmilk) equal in size; similar in
areola & nipples for color; soft and smooth;
tenderness, masses, P: Breast examination was both nipples point in the
nodules, discharge not done because the same direction; no
client refused to conduct discharge except for
the examination postpartum women
(breastmilk), no lesions.

ABDOMEN ABDOMEN I: Unblemished skin, Purplish striae and

uniform in color, linea nigra are normal.
I: skin integrity, contour I: The skin is intact, symmetric contour, not (BATES, Pocket Guide
& symmetry, hernia, symmetrical, Slight to Physical
distended. Symmetrical
distention (girth), vertical line discoloration Examination, page 367)
movements associated movements caused by
(Linea Nigra), stretch respirations.
w/ respiration, marks and not distended,
peristalsis & aortic The movements of
pulsations abdomen is associated
with respirations.

GENITALS GENITALS For Females: Scars from an

I: Evenly distributed pubic episiotomy, a perineal
For Females: For Females: hair, no inflammation, laceration to facilitate
I: pubic hair distribution, swelling or any lesions. delivery of an infant, or
amount, characteristics; from a perineal
I; Pubic hair is evenly :No discharge or laceration may be
its areas for parasites, distributed, there is no inflammation in the present in multiparous
inflammation, swelling, inflammation, swelling or women. (BATES, Guide
lesions

23
 : clitoris, urethral and any lesions. Scars on the clitoris, urethral and to Physical
vaginal orifices for perineum vaginal orifices Examination and
inflammation or History Taking page
discharge :No discharge or 422)
inflammation in the clitoris,
urethral and vaginal
orifices

Table 8 Focused Assessment of Client F.S.M.

X. DIAGNOSTIC TEST
A. NON-INVASIVE
Specific Test Actual Finding Normal Finding Clinical Significance

TRANSVAGINAL Uterus is Uterus: Anteverted Placental adherence is also

ULTRASOUND Anteverted associated with a deficiency of
Cervix: Intact decidua in the lower segment,
December 7, 2022 Cervix is Closed the most common cause of
Ovaries: Ovaries are
which is endometrial scarring
Ovaries: normal in size and do not
secondary to previous history
have any cyst.
Right : 3.9 x 2.2 of cesarean section or
cm with small myomectomy, endometritis,
follicles. evacuation of retained products
of conception or uterine
Left : 3.9 x 1.8 cm abnormalities (Pathophysiology
with small follicles of Postpartum Hemorrhage and
No retained product of Third Stage of Labor page 98).
w/ some retained
product of conception
conception

Table 9 Non- Invasive Diagnostic Tests of Client F.S.M.

The result of the transvaginal ultrasound performed by Client FSM taken last

December 07, 2022, showed that the client has no any complication in her uterus,

cervix and ovaries. However, there are some retained product of conception upon the

postpartum ultrasound. After the ultrasound, her physician gave her an oxytocin

capsule and the physician does not recommend any procedure as the retained product

of conception are cooperating with her body as it slowly gets out of her uterus. After

how many days of taking the oxytocin capsule, there is no bleeding that occur

B. Invasive

Specific Actual Normal Finding Clinical Significance

Test Finding
FBS (Sept. Result: 74 74-100 mg/dl
21, 2022)
CBC WBC: 9.3 5.0 - 10.0x10

24
 (Sept. 21, RBC: 3.47 F: 3.8 - 5.8x10* 12/L A slightly low hemoglobin count isn't
2022) M: 4.0 - 5.9x10* 12/L always a sign of illness — it can be normal
for some people. Women with menstrual
periods and pregnant women commonly
have low hemoglobin counts (CLINICAL
HEMATOLOGY 5th EDITION by TURGEON
page 170)

Hemoglobin: F: 12 - 16 g/dL When the hemoglobin level is low, the

10.7 M: 14 - 18 g/dL patient has anemia. An erythrocytosis is
the consequence of too many red cells; this
results in hemoglobin levels above normal
(CLINICAL HEMATOLOGY 5th EDITION by
TURGEON page 109)

Hematocrit: F: 36-45% A low hematocrit level means there are too

30.4 % few red blood cells in the body. In these
cases, a person may experience symptoms
that signal anemia. Common symptoms
include fatigue, weakness, and low energy
(CLINICAL HEMATOLOGY 5th EDITION by
TURGEON page 371)
Platelet Count: 150 - 450 x 10 /L
250
Table 10 Invasive Diagnostic Tests of Client F.S.M.

The laboratory findings that were performed to client FSM, shows that there

are some abnormal findings found on her FBS & CBC last September 21, 2022. The

result of FBS of the client is 74 and the normal findings for FBS is 74 - 100 mg/dl. The

findings for WBC are normal, the findings is 9.3 and the normal values for that is 5.0 -

10.0 X 10. For RBC the result is 3.47 the normal values of RBC for females is 3.8 - 5.8

x 10. Her hemoglobin is 10.7 and the normal values for females of hemoglobin is 11.2

- 15.7 g/dL. The hematocrit is 30.4 and the normal values of females for hematocrit is

34 - 45 %.

25
8 XI. PATHOPHYSIOLOGY

Figure 3. Pathophysiology of Postpartum Hemorrhage

26
 Postpartum Hemorrhage was identified as the client's condition, it is when a

mother experience heavy bleeding after giving birth. There is a lot of factors on why

PPH occurs, on the Client’s case she experienced retained placenta which causes the

postpartum hemorrhage. There is no signs or symptoms in Postpartum hemorrhage

because this happens at the latter part of delivery.

Factors why client FSM was diagnosed with retained placenta was due to her

age, FSM is a 36 years old female, Maternal age is very important as 35 years old and

above are considered as high risk pregnancy. Multiparity can also be one of the causes

of retained placenta resulting to PPH, as our client OB score is gravida 5 parity 5 (5005),

The risk of Retained Placenta increases as your number of pregnancies increases.

FSM had gone through an epidural anesthesia to perform a dilation curettage

procedure to remove the retained tissue that is planted too deeply in the uterus. Client

FSM is fully recovered as she verbally stated but she is still on her maternity leave and

advised to rest well by her physician to be physically and mentally prepared for ligation.

A. ANATOMY

The organs of the female reproductive system produce and sustain the female

sex cells (egg cells or ova), transport these cells to a site where they may be fertilized

by sperm, provide a favorable environment for the developing fetus, move the fetus to
27
the outside at the end of the development period, and produce the female sex

hormones. The female reproductive system includes the ovaries, Fallopian tubes,

uterus, vagina, accessory glands, and external genital organs. Reproduction is all

about making babies, and the female reproductive system is specialized for this

purpose. Its functions include producing gametes called eggs, secreting sex hormones

(such as estrogen), providing a site for fertilization, gestating a fetus if fertilization

occurs, giving birth to a baby, and breastfeeding a baby after birth. The only thing

missing is sperm Pregnancy is the carrying of one or more offspring from fertilization

until birth. This is one of the major functions of the female reproductive system. The

maternal organism plays a critical role in the development of the offspring. (Suzanne

Wakim Mandeep Grewal,2022)

8.1 CLIENT-BASED (ONLY THOSE FACTS RELATED TO THE CASE ARE INCLUDED)
1. Postpartum hemorrhage is a major cause of maternal morbidity and mortality
2. The major causes of postpartum hemorrhage are uterine atony, lacerations,
retained placenta or clots, and clotting factor deficiency.
3. Medicine or uterine massage to stimulate uterine contractions, removing pieces
of the placenta that remain in the uterus. Exam of the uterus and other pelvic
tissues, the vagina, and the vulva to look for areas that may need repair
4. Losing lots of blood quickly can cause a severe drop in your blood pressure.
This may lead to shock and death if not treated.
5. A hysterectomy may be required after delivery to remove the placenta and end
blood loss
6. Conditions with varied placental site or attachment

28
9 XII. CASE MANAGEMENT
A. DRUG STUDY
Drug Features Therapeutic Effects Nursing responsibilities
Brand Name: Indication Contraindication Desired Untoward Before:
Methergine Methylergometrine Methylergometrine Methylergometrine Dizziness -Check blood pressure, monitor respiratory rate,
Maleate is indicated Maleate is Maleate desired is to Headaches heart rate, and uterine response frequently
Generic Name: as postpartum or contraindicated in, prevent or treat Nausea during medication administration
Methylergonovine post abortion Hypersensitivity bleeding from the Vomiting -Assess for any evidence of bleeding before
maleate hemorrhage caused uterus that can happen Chest pain administration
by uterine atony or Lactation: The baby after childbirth Muscle Pain -Educate the client about their medication
Dosage: 0.2mg subinvolution should not Weakness
Frequency: 3x a day or be breastfeed during After:
every 8 hours treatment -Notify physician if BP suddenly increases or if
Route: Oral there are frequent periods of uterine relaxation.
Brand name: Malunggay Malunggay capsule is Malunggay capsule is Malunggay Capsule Rash, itching, Before:
Capsule a well-known health contraindicated in desired is to boost swelling -Advise the client to take iron supplements an
Generic Name: supplement to help patients with Immunity (especially of hour before meals for maximum absorption
Moringga Olifera stimulate milk Hypercalcemia, the face,
secretion. A Hyperkalemia, tongue, throat) After:
Dosage: 500mg supplement that Sarcoidosis, Supports Breastfeeding Severe -Advice client that stools may become dark
Frequency: Once a day improves to letdown Nephrolithiasis, Severe Mothers dizziness. green or black and this change is harmless
Route: Oral the milk and Renal failure and Trouble
increases milk Hypersensitivity. to protects against free breathing
production. It is radicals that can Hypercalcemia,
known as lactation damage hair and skin Nausea
enhancer Vomiting.

Brand name: Treatment for a wide It is contraindicated Multivitamins + Iron Constipation Before:
SANGOBION IRON+ range of anemias; with impaired renal & Calcium Sangobion dark stool -Advice client to take medicine once a day
CAPSULE Iron deficiency functions, Iron desired is to helps Nausea/ -Educate the client about her medication.
Generic Name: anemia during nephrolithiasis replenish iron stores Vomiting
Multivitamins & pregnancy growth. hypersensitivity to and increases red Abdominal After:
Minerals megaloblastic and multivitamins blood cell levels in the Pain -Discontinue if side effects may occur Assess
macrocytic undiagnosed anemias body palpitations history of allergic reaction with drug.
Dosage: 250mg hypochromic
Frequency: Once a day anemias Chest pain
Route: Oral
Table 11 Drug Study of Medication taken of Client F.S.M

29
10 XII. NURSING MANAGEMENT

IV. LISTING OF NURSING PROBLEMS

I. POSTPARTUM HEMORRHAGE
II. RETAINED PRODUCT OF CONCEPTION
III. MULTIPARITY
V. PRIORITIZATION OF NURSING PROBLEMS

Problem 1: Postpartum Hemorrhage

Criteria Weight Multiplie Computati Justification
r on

Nature and 3 Actual 1 3/3 x 1 = Postpartum hemorrhage (PPH) is

Extent Problem 1 severe vaginal bleeding after
2 Risk / childbirth. It’s a serious condition
Potential that can lead to death. It causes a
1 Wellness
State
sharp decline in blood pressure,
which can restrict blood flow to
your brain and other organs. This
is called shock, and it can lead to
death

Modifiability 2 Easily 2 1/1 x 2 = Partially modifiable because the

Modifiable 2 healthcare provider can monitor full
1 Partially medical history of a client closely
Modifiable
during and after check up
0 Non
Modifiable

Preventive 3 High 1 2/2 x 1 = sharing a complete medical history

Potential 2 Moderate 1 and symptoms in a healthcare
1 Low provider is important. By Ensuring
adequate iron intake and red blood
cell levels during pregnancy can
minimize the impact of postpartum
hemorrhage

Salience 2 Needs 2 2/2 x 2= 1 It needs immediate action because

immediate Postpartum Hemorrhage is a life
attention threatening condition that may lead
action to death if not treated properly and
1 Not needing
immediate immediately.
attention
0 Not perceived
as a problem/
condition
needing change

TOTAL 5 Priority # 1

Table 12.1 Postpartum Hemorrhage

30
Problem 2: Reta
Criteria Weight Multiplier Computation Justification

Nature and 3 Actual 1 2/3 x 1 = 0.67 Retained products of

Extent Problem
2 Risk / conception (RPOC) occur
Potential when fetal or placental tissue
1 Wellness remains in the uterus after a
State
pregnancy ends. Symptoms
can include abnormal vaginal
bleeding, fever or infection.

Modifiability 2 Easily 2 2/2 x 2 = 2 The problem is easily

Modifiable
1 Partially modifiable; this problem can
Modifiable prevent by teaching the client
0 Not to make sure that the
Modifiable
healthcare provider knows the
full medical historycase, for the
monitor of the health of client
closely during and after any
future pregnancies.

Preventive 3 High 1 3/3 x 1 = 1 The preventative potential is

Potential 2 Moderate
1 Low
moderate because this
situation can be prevented by
having a discipline to herself,
like maintaining healthy diet
and attending all appointments
and lastly by following the
instructions of her physician.

Salience 2 Needs 1 2/2 x 1 = 1 It needs immediate action and

immediate
attention
immediate attention to prevent
action complication.
1 Not
needing
immediate
attention
0 Not
perceived
as a
problem/
condition
needing
change

31
 TOTAL 4.67 Priority # 2

Table 12.2 Retained Product of Conception

Problem 3: Multiparity

Criteria Weight Multiplier Computation Justification

Nature and 3 Actual 1 3/3 x 1 = 1 Client's maternal age is 36

Extent Problem
2 Risk /
and with an ob score of
Potential G5P5(5005) which mean the
1 Wellness risk of unfavorable outcomes
State
can increase her chances of
pregnancy complications.

Modifiability 2 Easily 2 1/1 x 2 = 2 Partially Modifiable This

Modifiable
1 Partially
situation or problem can be
Modifiable solved by informing having a
0 Not family counseling to choose
Modifiable
method of family planning.

Preventive 3 High 1 1/3 x 1 = 0.33 Preventative Potential is high

Potential 2 Moderate
1 Low because the more times a
woman becomes pregnant
and gives birth, the less
efficient her uterus is at
contracting and returning to its
normal size. This can cause
problems during and after her
labor

Salience 2 Needs 1 2/2 x 1 = 1 It needs immediate action and

immediate
attention
immediate attention because
action multiparity is a great risk for
1 Not many fetal and maternal
needing
immediate
complications including
attention postpartum hemorrhage and
0 Not prematurity
perceived
as a
problem/

32
 condition
needing
change

TOTAL 4.33 Priority # 3

Table 12.3 Multiparity

Health Problems Score

Postpartum Hemorrhage 5

Perineal Laceration 4.67

Unhealthy Diet 4.33

Table 13. Problems ranked according to the Prioritization

Based on our findings. There are three lists of problems contained in the case
presentation, these are Hemmorrhage, Pain in Perineal Laceration, and Multiparity
Each problem had a computation which showed where or what the location of each
problem was. First, our first priority and the main problem Hemmorrhage with a total
score of 5 Second, Perineal Laceration with a total score of 4.67 and finally
Multiparity with a total score 4.33. Scores are obtained based on the patient's case
made by nursing management

33
 XIII. PLANS FOR NURSING ACTION

A. HEALTH CARE PLAN

Problem #1: Postpartum Hemorrhage
Assessment Diagnosis Planning Implementation Evaluation
Subjective Independent Rationale
“Marami parin yung Risk for ineffective tissue After 2 hours of  Establish rapport.  For nurse/midwife-client After 2 hours of
nararamdaman kong perfusion related to intervention, the client relationship. intervention, the goal
nalabas sakin na dugo.” hemorrhage. will demonstrate  Assess  The amount of blood during first was not met because
as stated by the client. adequate perfusion characteristics and few hours after delivery should the patient was
and stable vital signs. amount of blood. be no more than one saturated referred to the other
Objective perineal pad per hour. facility to receive
 Vital sign taken as  Monitor client’s vital  Rise in pulse rate may indicate D&C procedure.
follows: signs. the inadequate blood volume
CR: 65 bpm and decrease in blood pressure
RR: 22 cpm may also occur.
T: 36.7 °C  Gently massage the  To help expel blood clots and to
 Capillary refill: > 3 fundus of the uterus check the tone of the uterus to
seconds of the client. prevent excessive bleeding.
 Pale lips  Count and weigh the  Estimated count of blood loss in
 Pale conjunctiva client’s perineal given lengths of time can be
pads. formed.

 Provide comfort to  For the client to be relaxed and

the client such as it may enhance the client’s
back rubs, deep coping abilities by redirecting
breathing. As well as their attention.
instructing the client
in relaxation
exercises.

Dependent To promote contraction and to

Administer medications prevent further bleeding.
as ordered.
Table 14.1 Health Care Plan on Postpartum Hemorrhage

34
 Problem #2: Retained Product of Conception

Assessment Diagnosis Planning Implementation Evaluation

Subjective Independent After the interventions, the
“7 days after nung D&C Risk for bleeding related to  The client will have  Keep fluids within  to encourage fluid intake client was able to meet the
ko, meron paring dugon retained product of less blood flow of less reach of the client. goal:
a nalabas. Parang heavy conception as evidenced than 2 saturated pad in  Establish rapport.  For nurse/midwife-client
menstrual flow.” As by excessive blood loss. a day. relationship. 1. The client was able to
verbalized by the client.  The client’s discomfort expel the remaining
Objective will lessen.  Assess characteristics  The amount of blood product of conception with
 Soaked perineal  The client will and amount of blood. during first few hours the help of the prescribed
pads (2-3pads per demonstrate vital signs after delivery should be medication
hour) no more than one (methylergometrine meate
within normal range.
saturated perineal pad
 Transvaginal or methergine tablets).
per hour.
ultrasound result: 2. Client’s vital signs are
CONSIDER SOME within normal range.
 Monitor client’s vital  Rise in pulse rate may
RETAINED indicate the inadequate 3. The client was able to feel
signs. relieved after the
PRODUCT OF blood volume and
CONCEPTION decrease in blood intervention/s.
pressure may also occur.

 Count and weigh the  Estimated count of blood

client’s perineal pads. loss in given lengths of
time can be formed.

 Provide comfort to the  For the client to be

client such as back relaxed and it may
rubs, deep breathing. enhance the client’s
As well as instructing coping abilities by
the client in relaxation redirecting their attention.
exercises.
Dependent
Administer medication as To promote contraction and to
per doctor’s order prevent further bleeding.
Table 14.2 Health Care Plan on Remained Product of Conception

35
 Problem #3: Multiparity

Assessment Diagnosis Planning Implementation Evaluation

Subjective Independent After the interventions, the
“nakalima na nga ako High-risk Pregnancy.  The client will have  Discussing about the  to give the client more client was able to meet the
dahil sa pills, knowledge about the risk in pregnancy insight about her status. goal:
nakakalimot din kasi ako risk in pregnancy 1. Knowledge about the
ng paginom kaya ngayon  The client will know  Establish rapport.  For nurse/midwife-client risk in pregnancy
di ko na din alam anong what family planning relationship. 2. Choosing the right
gagamitin.” As verbalized method suits for her family planning
by the client.  The client will get to  To provide more options method.
Objective choose the best family for the client and know
 G5 P5 (5005) planning method for what is suitable for her.
 her.

Dependent
To promote the importance of
Following the instructions
health teaching.
given.
Table 14.2 Health Care Plan on Multiparity

36
Teaching Plan
1. Postpartum Hemorrhage

Intended Content Strategies Resources Evaluation

outcomes

The client will be  Postpartum hemorrhage or  Visual aids or  The client was
able to do the severe bleeding after birth is Teaching Activity Learning informative able properly
following after defined as blood loss greater  Lectures and handouts will be listen and was
hours of health than 1,000cc of blood loss. discussions Activity used by student able to
education: Nonetheless, having blood with the client  The lecture will midwives. understand what
A. Define loss greater than 500cc in a or the closest be discussed by  Informative and is postpartum
postpartum vaginal delivery is guardian of it. a student interesting hemorrhage.
hemorrhage. considered abnormal.  Question and midwife. videos  The client must
B. Identify risks of  Factors that may lead-up to answer portion.  The student regarding recite the risk
having postpartum hemorrhage are:  Explaining it in midwife will postpartum factors that might
postpartum failure of uterus to contract a way they can discuss the risk hemorrhage. cause
hemorrhage. enough after vaginal easily factors and postpartum
C. Differentiate delivery, retained placenta, understand. causes of hemorrhage.
normal to maternal age of greater than postpartum  The client
abnormal vital 35 years, age of gestation hemorrhage. understands the
signs. below viability, anemia and  The student difference
D. Strategies on prolonged third phase of midwife between normal
how to improve labor. explained the and abnormal
her comfort.  Understanding of normal and ways to prevent vital signs.
abnormal limits of vital signs postpartum  The client’s
may help prevent problem hemorrhage comfort will be
occurrence. improved.
Table 15.1.Teaching Plan for Postpartum Hemorrhage

37
 2. Retained Product of Conception

Intended outcomes Content Strategies Resources Evaluation

The client will be able to do  Dilation & Curettage is a Teaching Activity Learning  Visual aids or  The client was able
the following after hours of procedure done to remove  Lectures and Activity informative properly listen and
health education: tissue from the inside of the discussions with  The lecture will handouts will be was able to
uterus. the client or the be discussed by used by student understand the risk
 Identify reasons  Heavy bleeding after D&C is closest guardian a student midwives. of having retained
why having a normal. of it. midwife.  Informative and product of
retained product of  Methylergonovine  Question and  The student interesting conception after
conception is a (Methergine) is given 3 days answer portion. midwife will videos delivery.
high risk. after the procedure and it  Explaining it in a discuss the risk regarding  The client must
 Differentiate helps to decrease bleeding way they can factors and perineal recite the risk
between normal as well as returning the easily causes of heavy lacerations. factors of having
lochia and uterus in its normal size. understand. bleeding after retained product of
abnormal lochia. (NANDA) D&C procedure. conception.
 Demonstrate  The student  The client has
some strategy on midwife understood the
how the patient explained the difference between
will be reminded ways to promote the normal lochia
about her comfort. and abnormal
medicine. lochia.
 Strategies how to  The client’s comfort
reduce the amount will be improved.
of bleeding.  The client will
always be reminded
to take her
medicine.
Table 15.2. Teaching Plan for Retained Product of Conception

38
 3. Multiparity

Intended outcomes Content Strategies Resources Evaluation

The client will be able to  Family planning method is a Teaching Activity Learning  Visual aids or  The client was
do the following after method that helps to reduce  Lectures and Activity informative able to properly
health education: the risk of maternal and discussions with  The lecture will be handouts will be listen and was
newborn death or illness by the client or the discussed by a used by student able to understand
 Knowledge preventing high-risk closest guardian student midwife. midwives. the high-risk
about the risk pregnancy in women or of it.  The student  Informative and pregnancy.
in pregnancy preventing unplanned  Question and midwife will interesting videos  The client must
 Choosing the pregnancy. answer portion. discuss the high- regarding perineal recite the risk
suitable family  High-risk pregnancy means a  Explaining it in a risk factors in lacerations. factors of high-risk
planning woman and her fetus face a way they can pregnancy pregnancy
method. above normal chance of easily  The student  The client has
experiencing problems. understand. midwife explained understood the
the importance of different types of
choosing the right family planning
family planning method.
method
Table 15.2. Teaching Plan for Multiparity

39
 XIV. DISCHARGE PLAN

Medication Exercise Treatment Health OPD Follow-up Diet Signs &

Education Symptoms
Methergine Type -Continue -Plan activities -Follow up check- Limits Do not hesitate to
medications as per with the client that up -Eating sweets, visit your nearest
Dosage: 0.2mg Light to moderate doctor’s order. can help reduce -ERS Maternity & salty as well as hospital if you
Frequency: 3x a intensity aerobic stress. Pediatric Care fatty foods. experience any
day or every 8 exercise (e.g. -Healthy diet Clinic -Limit until no abnormalities to
hours walking) during the -Advise clients to caffeine intake. your body.
Route: Oral postpartum period -Less caffeine drink lots of water
has the ability to intake. as well as the Inclusion
Malunggay improve mild to Eating healthy and
Capsule recommended
moderate -Exercise every non-caffeinated nutritious foods
Dosage: 500mg depressive morning. drinks. especially green
Frequency: Once symptoms leafy vegetables
a day (Lindberg, 2020) and fruits.
Route: Oral
Frequency
SANGOBION 10-20 minute walk
IRON+ CAPSULE every morning.

Dosage: 250mg
Frequency: Once
a day
Route: Oral
Table 16. Discharge Plan for F.S.M.

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 XV. RECOMMENDATION

Upon assessing the client, we would like to recommend that she continue

completely taking her prescribed medications daily and maintain a healthy lifestyle by

having a proper diet such as eating foods rich in iron such as talbos ng kamote,

kangkong, all green leafy vegetables and liver to prevent iron deficiency and to make

sure that her recovery is going well and there are no complications that may occur. We

do suggest that she continuously follows her doctor's recommendations and advice,

such as complying with her follow-up checkup to improve her current health status and

to avoid further aggravation.

We would also like to recommend doing exercise to have a better and healthier

life in all aspects. During assessment, the client perceives herself as someone who’s

always tired and sleepy. She easily loses interest and energy, which makes things

harder for her to accomplish. We recommended for her overall emotional and mental

health that she have meditation, try to be more patient, and extend her temper by

understanding and considering things and people.

Above all, we commend client F.S.M for her cooperation and attentiveness

during the interview as well as for seeking and following a professional’s advice when

it comes to health and for her to believe and follow it.

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11 PAMPHLET (ENGLISH)

42
12 PAMPHLET (TAGALOG)

43
REFERENCES

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Briones, J. R., Talungchit, P., Thavorncharoensap, M., & Chaikledkaew, U. (2020).

Economic evaluation of carbetocin as prophylaxis for postpartum hemorrhage
in the Philippines. BMC Health Services Research, 20(1), 975.
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Evensen, A., Anderson, J. M., & Fontaine, P. (2017). Postpartum hemorrhage:

Prevention and treatment. American Family Physician, 95(7), 442–449.
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Hossain, N., Langhoff-Roos, J., & Paidas, M. J. (2011). Postpartum Hemorrhage.

In Hemostasis and Thrombosis in Obstetrics & Gynecology (pp. 167–181).
Wiley-Blackwell.

Yamashita, T., Suplido, S. A., Ladines-Llave, C., Tanaka, Y., Senba, N., & Matsuo,
H. (2014). A cross-sectional analytic study of postpartum health care service
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Borovac-Pinheiro, A., Pacagnella, R. C., Cecatti, J. G., Miller, S., El Ayadi, A. M.,
Souza, J. P., Durocher, J., Blumenthal, P. D., & Winikoff, B. (2018).
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Marshall, A. L., Durani, U., Bartley, A., Hagen, C. E., Ashrani, A., Rose, C., Go, R. S.,
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Care after your D&C. (2010, January). University of Washington Medical Center.
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Lochia (Postpartum Bleeding): How Long, Stages, Smell & Color. (n.d.). Cleveland
Clinic. https://my.clevelandclinic.org/health/symptoms/22485-lochia

Belleza, R. M. N. (2017, January 18). Postpartum Hemorrhage. Nurseslabs.

https://nurseslabs.com/postpartum-hemorrhage/
Singh, A. (2020, January 3). Postpartum Hemorrhage - Causes, Symptoms,
Diagnosis, Treatment, Prevention. Medindia.
https://www.medindia.net/patients/patientinfo/postpartum-hemorrhage.htm

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APPENDICES

CONSENT FORM

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