GHDG

1. FINAL CASE PRESENTATION
TAGOLOAN COMMUNITY COLLEGE
COLLEGE OF MIDWIFERY
Prepared by:
CABARDO, JOYCE C.
MID 2B

2. DEMOGRAPHIC DATA:
•PATIENT M
BIRTHDAY: March 31,1992
AGE: 30 years old
SEX:FEMALE
RELIGION: Roman Catholic
CIVIL STATUS: Single
ADDRESS: Zone 7 Sihayon, Sta. Cruz , Tagoloan,Misamis Oriental
OBSTETRICAL HISTORY:
Menarche: 13 years old
Days of Menstruation: 3-5 Days
Coitarche: 20 years old

3. HISTORY OF PREVIOUS PREGNANCY:
Pregnancy
Type of
Delivery
Date of
Delivery
Sex of the
baby
Name of
Facility
Complications
If any
TETANUS TOXOID
TT1-(✓) 2013. TT2-(✓) 2017. TT3-(✓) JANUARY 26,
2023
1
2
3
2013
2017
2023
NSVD
NSVD
NSVD
NMMC
ST. PAUL
HOSPITAL
ST. PAUL
HOSPITAL
MALE
FEMALE
MALE
N/A
N/A
N/A

4. PRESENT PREGNANCY:
GPTPAL:
G- P- T- P- A- L-
G-3 P-3 T-3 P-0 A-0 L-3
LAST MENSTRUAL PERIOD:
May 17, 2022
Expected Date of Delivery:
February 24,2023
5 17 2022
-3 + 7 + 1
=2 24 2023
=291

5. PRENATAL RECORDS OF
PRESENT PREGNANCY

6. 1st
Visit
LEOPOLD’S MANUEVER RESULT:
Health Teaching:
•To come back once week
Follow up 1/20/23 with no signs and symptom with RPS
•Medication:
DATE: December 23,2022
AOG: 31 weeks and 3days
VITAL SIGNS: BP: 90/60mmHg WEIGHT:56.6kl TEMPERATURE:36.2°C
PULSE RATE: 101bpm RESPIRATORY RATE: 19cpm
FUNDIC HEIGHT:30cm
FETAL HEART TONE:141bpm
L1: FUNDAL GRIP: ASYMMETRICAL, SOFT = BUTTOCK
L2: LATERAL GRIP: FLAT AND FIRM= RLQ/153bpm
L3: PAWLIC GRIP: CEPHALIC PRESENTATION
L4:PELVIC GRIP: NOT ENGAGED

7. 2nd
Visit
LEOPOLD’S MANUEVER RESULT:
Health Teaching:
Medication:
L1: FUNDAL GRIP: ASYMMETRICAL, SOFT = BUTTOCK
L2: LATERAL GRIP: FLAT AND FIRM= RLQ/150bpm
L3: PAWLIC GRIP: CEPHALIC PRESENTATION
L4:PELVIC GRIP: NOT ENGAGED
DATE: January 20, 2023
AOG:
VITAL SIGNS: BP: 90/60mmHg WEIGHT:56.6kl
TEMPERATURE:36°C
PULSE RATE: 101bpm RESPIRATORY RATE: 19cpm
FUNDIC HEIGHT:31cm
FETAL HEART TONE:134bpm
35weeks and 3 days
•To come back once week
Follow up 2/27 with no signs and symptom with RPS

8. 3rd
Visit
DATE: February 27, 2023
AOG:
VITAL SIGNS: BP:120/90mmHg WEIGHT:56.8kl
TEMPERATURE:36.2°C
PULSE RATE: 91bpm RESPIRATORY RATE: 18cpm
FUNDIC HEIGHT:33cm
FETAL HEART TONE:138bpm
LEOPOLD’S MANUEVER RESULT:
L1: FUNDAL GRIP: ASYMMETRICAL, SOFT = BUTTOCK
L2: LATERAL GRIP: FLAT AND FIRM= RLQ/153bpm
L3: PAWLIC GRIP: CEPHALIC PRESENTATION
L4:PELVIC GRIP: NOT ENGAGED
Health Teaching:
Medication:
41weeks and 1day

9. ADMISSION HISTORY
DATE OF ADMISSION: March
04,2023
CHIEF COMPLAIN: Labor Pain
VITAL SIGNS:
BP:130/100mmhg PULSE RATE: 80bpm
RESPIRATORY RATE:19
TEMPERATURE:36.6°C

10. LABOR WATCH:
•FIRST IE
Time: 12:00pm
Cervical Dilatation: 6cm
Effacement: 70% Station: -1
BP: 130/100mmhg
Temp.: 36.6°C
Pulse:80bpm
RR:19bpm
O2SAT:98%
FHT: 154bpm
Urine Voided: No
BOW: INTACT
CONTRACTION in 10 mins.
FREQUENCY:4mins
DURATION:60seconds
INTENSITY: MODERATE
INTERVAL: 3mins

11. •
12:00
pm
2
154bpm
No
36.6°C
80bpm
130/100
6cm
I

12. •SECOND IE
Time: 4pm
Cervical Dilatation: 8cm
Effacement: 90% Station: +1
BP: 120/80
Temp.: 36.6°C
Pulse:83bpm
RR:19bpm
O2SAT:97%
FHT: 140bpm
Urine Voided: Yes
BOW: Meconium
CONTRACTION in 10 mins.
FREQUENCY:3mins
DURATION:60secs
INTENSITY: STRONG
INTERVAL: 2min
LABOR WATCH :

13. 2-3
154bpm
NO
36.6°C
80bpm
130/100
6cm
I
•
1pm
M
3
140bpm
Yes
36.9°C
83bpm
120/80
8cm
4pm
•

14. •THIRD IE
Time: 6:00pm
Cervical Dilatation: 10cm
Effacement: 100% Station: +1
BP: 110/100mmhg
Temp.: 36.6°C
Pulse:90bpm
RR:19bpm
O2SAT:98%
FHT: 160bpm
Urine Voided: Yes
BOW: Meconium
CONTRACTION in 10 mins.
FREQUENCY:2mins
DURATION:60seconds
INTENSITY: STRONG
INTERVAL: 1min
LABOR WATCH

15. 12pm 4pm 6pm
2
154bpm
NO
36.6°C
80bpm
130/100
5cm
M
. 3
140bpm
Yes
36.9°C
83bpm
120/80
6cm
4
160bpm
YES
36.2°C
90bpm
110/80
10cm
I M
•
•
•

16. MATERNAL OUTCOME
Patient M, 30 years old, pregnancy uterine 41weeks &
1day, cephalic presentation, delivered via NSVD to a
live baby boy, time of delivery 6:34pm of March 4,
2023, APGAR score of 9-10 with baby’s weight of
3.754 grams.
Placenta out at 6:39pm and oxytocin 10 IU given IM at
6:39pm.
Patient vital sign
BP- 110/90mmHg, PR- 89bpm, Temp. 36.2°C Rr-
19bpm
GPTPAL- G3P3

17. NEWBORN CARE
EINC PROTOCOL
 Newborn placed on abdomen of the mother.
 Immediate & thorough drying for 30 secs.
 Properly timed cord clamping done placenta expelled
 Completely weight 500 grams
 BP check 110/70 mmHg
 Uterus kept firm and well contracted.
 Repair 2nd degree laceration.
 Kept on uninterrupted skin to skin contact for 90 mins.
 Feeding cues noted.
 Breastfeeding initiated
 Final checking done
 Postpartum care done.

18. •NEWBORN
ASSESSMENT
Name: BABY BOY
Date/Time of Delivery: March 04,2023/6:34pm
APGAR Score: 9-10
Head: 33cm
Chest: 33cm
Abdomen: 31cm
Length: 52cm
•IMMUNIZATION
Baby Boy received Hep. B 0.5ml vaccine given Intramuscular at the right
upper portion of thigh.
 Vitamin K 0.1ml was given Intramuscular at the Left upper outer of
thigh.
 Erythromycin Eye Cream was given from inner to outer cantus.
• NEWBORN
VITAL SIGNS
PR- 66bpm
O2SAT- 96%
RR- 50cpm
Temp.- 37.8°C

19. POSTPARTUM:
The postpartum period begins immediately after childbirth, as the mothers
body including hormone levels and the uterus size, return to a no pregnant
state.
✅Monitor the uterus contracted.
✅Monitor Vital Signs every 15minutes for 1hour. then every 30 minutes for
2hrs.
POSTPARTUM MONITORING AND CARE
DATE: TIME: BP: TEMP: PULSE: O2Sat
March 04,
2023 6:40pm
7:10pm
7:40pm
8:10pm
130/90bpm
130/80bpm
120/70bpm
120/80bpm
36.4°C
36.1°C
35.7°C
36.7°C
RR:
85bpm
90bpm
96bpm
98%
95%
95%
23bpm
22bpm
20bpm

20. POSTPARTUM HEALTH TEACHINGHEALTH
TEACHING
✓Encourage breastfeeding
/Family Planning
✓/Immunization
✓ Nutrition
POSTPARTUM MEDICATION
•Mefenamic (1 cap)
•Cefalixin (1cup)
•Ferous Sulfate (1tab)