A Case Study On

Normal Spontaneous Vaginal Delivery

Post Partum Care

6 July 2009

I. INTRODUCTION

The student nurse chose this case for her study to apply what has been

discovered in the classroom and to further know the pathophysiology of the case.

That is to learn more about the patient’s condition. Out of curiosity, the student

nurse wants to know as to how or why many post partum patients would

experience such complications after giving birth and as to how closely the patient

should be monitored time to tie to rule out other possible complications. It also

serves as a knowledgeable experience for her to exploit if she encounters a

patient/s with similar condition. I t is known that infection is a big possibility if

patient with 4th degree laceration or any lacerations are uncared. Therefore, it is

important that student nurse understands exactly how much care is to e rendered

for such patients. The care that the mother obtains during this period affects her

health for the rest of her life.

 Pregnancy is the state of carrying a developing embryo within the female

body. When the growth and development of the fetus is completed, it undergoes the

process so called delivery.

The most common delivery in many hospitals and even in the community

setting is a normal delivery. This is more known as the Normal Spontaneous

Vaginal Delivery (NSVD) wherein the baby was delivered through the vagina.

During delivery, the mother is placed in a lithotomy position (supine with

her knees bent and legs raised). The an incision called episiotomy may then be

performed at this time which eases delivery of fetal head and letting some

supervision by the nurse ho handles to halt ore or bigger perineal lacerations.

Episiotomy is necessary in most first deliveries and even in many cases in multi-

gravid women.

There are two ways to do episiotomy. First, the Median Episiotomy, this is

the easiest episiotomy to accomplish and to repair and is certainly the most

bloodless. It includes incising the median raphe of the perineum almost to the anal

sphincter. The disadvantage of this procedure is the infrequent accidental extension

of the incision through the sphincter (3rd degree laceration) or though the sphincter

and into the lumen of the rectum (4th degree laceration).

 The second way is the Mediolateral Episiotomy. This is the most widely

used in operative obstetrics because of its safety. Incise downward and outward in

the direction of the lateral margin of the anal sphincter. The advantage of this

procedure is that extension through sphincter is uncommon. The disadvantage,

however, are more difficult to repair and has a greater blood loss.

Perineal repair after episiotomy or spontaneous obstetric laceration is one

of the most coon surgical procedures. Effective repair requires knowledge of

perineal anatomy and surgical technique. Fast healing of the repaired perineum can

be achieved through thorough care.

In this case study, the student nurse expects additional information and

knowledge that she can gain, to acquire more comprehensive plan of care for

patient’s who have given birth and also to improve her management ability for post

partal patients.
II. OBJECTIVES

General Objective:

After 2 days of student nurse – patient interaction, the student

nurse will be able to provide holistic care and improve her attitude, skills and

knowledge in the care of a postpartum patient who has given birth.

Specific Objectives:

Student nurse centered

After 2 days of rendering holistic nursing care, the student nurse

will be able to:

1. establish rapport with client and his/her significant others.

2. perform thorough nursing assessment by:

 2.1 obtaining patient’s personal history

2.2 obtaining family and individual information, social and health

history

2.3 acquiring patient’s level of growth and development

3. identify present nursing problems

4. discuss the following:

4.1 anatomy and physiology of organs and systems affected in

patient’s condition

4.2 normal levels of growth and development

5. impart health teaching to patient and gamily regarding present

condition as to the following:

5.1 potential complications

5.2 management to prevent complications

5.3 post partum care

5.4 care for the newborn

6. formulate a comprehensive nursing care plan for the patient and

implement it.

7. evaluate effectiveness of the care given to the patient.

Patient Centered

General Objectives:

After 2 days of student nurse-patient interaction, the patient and

family will be able to:

 1. establish and achieve communication with the student nurse.

2. participate proactively in the assessment process.

3. identify the potential problems/complications in Post Partum state.

4. verbalize understanding of the scope and nature of delivery.

5. experience relief of signs and symptoms during student nurse care.

6. apply learned nursing care or measures.

III. NURSING ASSESSMENT

1. Personal History

1.1 Patients Profile

Name: Mrs. Latoy, Catherine Paquibot

Age: 28 years old

Sex: Female

Civil Status: Married

Religion: Roman Catholic

Date of Admission: May 5, 2009

Room No.: Obstetric Ward 4

Complaints: Pain in the perineum/perineal area

Impression/Diagnosis: Pregnancy Uterine delivered

Cephalic a Term Live Male Neonate, AS =9,10

 Birth weight= 3.55 kilograms. Premature Rupture

of Membrane (16hrs) Gravida 2 Parity 1 (1011)

Operation: Median episiotomy plus repair of fourth degree perineal

laceration

Physician: Doctor Alqueza, Mary Faith

1.2 Family and Individual information, social and health history

A case of Mrs. Latoy, Catherine, 28, Female, Married to Mr.

Latoy, Javelle. Patient works as a Quality Controller in MEPZ. Gravida 2

Parity 1 (1101). The patient complains about the pain on her genitalia due

to her fourth degree perineal laceration repair. Patient was admitted last

May 5, 2009 due to regular uterine contractions and signs and symptoms

of true labor. May 6, 2009, she gave birth through Normal Spontaneous

Vaginal Delivery. Her labor started at around 6 PM. She had a premature

rupture of membrane for 16 hours.

Mrs. Latoy, Catherine is a Gravida 1, Parity 2 (1011). It is then

obvious that the patient had a history of abortion. This abortion happened

last year as verbalized by the patient. During her labor, Mrs. Latoy had a

median episiotomy and a repair of her fourth degree perineal laceration.

She was placed in a lithotomy position. Patient has no hypertension,

diabetes, renal disease, and allergies history. She doesn’t smoke, drink

alcohol, but prefers water and juice and sometimes soft drinks. Mrs.

Latoy, Catherine has verbalized that she tool some vitamins during her

pregnancy and that she loves to eat that time. These information can be

related to her baby’s weight, 3.55 kilograms. A very healthy baby that

causes fourth degree perineal laceration.

1.3 Level of growth and development

1.3.1 Normal development at Particular Stage

Young Adults  20-40 years old

• Physical Development

The Young adult has completed physical growth by the age of

20. The musculoskeletal system is well developed and coordinated.

All other systems of the body are also functioning at height

efficiency. Through diet and exercise physical and psychosocial

changes occur in pregnant and lactating women.

• Cognitive Development

Piaget believed that young adults thinking moves to

abstract and theoretical subjects in the formal operations period.

Thinking can jeopardize into such subjects as attaining world

peace, finding justice, and seeking meaning in life. Formal and

informal educational experiences, general life experiences, and

occupational opportunities dramatically increase the individuals’

conceptual, problem-solving and motor skills. Identifying preferred

occupational areas is a major task of young adults.

• Psychosocial Development

- Intimacy vs. Isolation

The developmental crisis in this stage according to Erikson

is achieving a sense of intimacy versus isolation. Choices must be

formed about education and profession or employment, whether to

enter the world of marriage or single hood, about to start a home,

and about bearing or to have children or not. Social responsibilities

include forming new friendships and assuming some community

activities.

This period is termed the “genital phase”. Freudian theory

considers the main events of this period to be the establishment of

new sexual aims and the finding of new love objects.

Young Adults have the following developmental tasks:

selecting a mate, learning to live with a marriage partner, starting a

family, rearing children, getting started in an occupation, taking on

civic responsibilities, and finding a congenial social group.

• Moral Development
 Young adults are expected to have mastered the previous

stages of Kohlberg’s theory. At this stage, the person is able to

separate self fro the expectations and rules of others. Young adults

define morality in terms of personal principles. When individuals

encounter a conflict with Society’s laws and regulations, they

decide according to their own principles. Men explain moral

problems in terms of rules and rights and often use an “ethic of

justice”. Women, on the other hand, usually define moral problems

in terms of obligation to care and to avoid harm.

1.3.2 The ill person at particular stage of patient

Traditionally, it is assumed that the bulk of a woman’s

concern in the post partum period centers on the care of her new

baby. With this, lessons in the postpartum period have traditionally

centered on teaching how to breast-feed and bath infants. Although

these acts are concerns for many mothers, they are not necessarily

a new mother’s chief concern. She has come through a tremendous

physiological experience during pregnancy and the birth of a child.

It is then expected that mother’s attention and interest during this

time will be directed to her full recovery. This is for her to take

care of her new baby without worries/concerns. This is also for her

to take good care of the baby with full attention.

 In the case of Mrs. Latoy, her concern as of the moment is

her full recovery. She visits her baby in the nursery room when she

misses it. The patient does not mind the pain related to her fourth

degree laceration. The patient sees to it that she will have a fast

recovery so that she can be able to take care of her baby fully. She

has not yet breastfeed her baby because she finds it painful still.

This is also one of the reasons why she wants a fast recovery. She

cannot afford to feel two pain at the same time (pain during

breastfeeding and pain in the perineum.)

2. DIAGNOSTIC RESULTS

Diagnostic Test Normal Value Result Significance

May 6, 2009
HEMATOLOGY
Hemoglobin 12.3 – 15.3 10.7 g/dL ↓ = anemic
Hematocrit 35.9 – 44.6 32.9 % ↓= anemic
RBC 4.50 -5.90 3.83 10^12/L ↓ = anemic
WBC 4,000 – 11,000 11,950 10^3/L ↑ = infection
MCV 80 – 96 86 fl Normal
MCH 27 – 31 28 Normal
MHCH 32.0 – 36.0 33 Normal
Platelet Count 150,000 – 450,000 415,000 10^3/L Normal
- Neutrophil 40- 70 78 % ↑ = infection
- Basophils 0–1 0% Normal
-Eosinphils 1–5 4% Normal
-Lymphocytes 20 – 40 11 % ↓ = infection
-Monocyte 0–8 7% Normal
URINALYSIS
* Macroscopic
Color Yellow- Light yellow Yellow Normal
Transparency Clear Sl. Cloudy Possible infection
Reaction 5.0
Sp. Gravity 1.016 – 1.022 1.035 ↑ = decreases renal
 perfusion
Protein - - Normal
Glucose - - Normal
Ketones - +2 Ketonuria
Blood - +1 Hematuria
* Microscopic
RBC/hpf 0–2 3–5 ↑ = Hematuria
WBC/hpf 0–2 6 – 10 ↑ = infection
Epith. Cells More / few Rare Has infection
Mucus Threads - Few Has infection
Bacteria - Rare Has infection
* Crystals
A-Urates - Rare The speciment has

been allowed to

stand
SEROLOGY
Latex Fixation (RA) - < 8 u/mL Normal
HBSag Qualitative More reactive - -
HB-AG Qualitative Non reactive - -
C3 83 – 177 mg/dL 90 – 180 mg/dL Some inflammatory

disease
Source: Lippincott Manual of Nursing Practice 6th edition

PHYSICAL ASSESSMENT (IPPA)

BODY PART I P P A

Round, normal,
Head symmetric
Long, slightly dry
Hair
Symmetric, no
Face pimples
Hair evenly
Eyebrows distributed,
symmetrical,
aligned
Evenly
Lashes distributed
 Iris Black in color
Without
Visual Acuity eyeglasses, can
read
Peripheral Can see the
Vision objects at
periphery
Muscle function Eyes were able to
follow direction
of objects
Symmetrical, at
Nose midline of the
face
Mouth Slightly pale

Abdomen Round, presence

of Linea Nigra
EXTREMITIES
Arms reacted
Upper Brown in color PR = 88 bpm when hit by BP = 110/70
Extremities and able to move Temp = 36.9 hammer
Warm, no
lesions, strong
Legs reactive
Lower Brown in color, Tibial and to percussion
Extremities able to walk but dorsalis pedis hammer
slowly, pain upon pulse are
standing and palpable
moving
Breast Symmetrical
Genitalia Has stitches

SKIN Fair in color, dry, Smooth, warm,

perspiration good skin turgor
present, absence
of lesions

3. Present profile of Functional Health Patterns

3.1 Health perception / Health Management Pattern

Mrs. Latoy during the assessment verbalized that she is okay but her

episiorrhaphy (perineal repair) is painful. The pain is getting better from

 the scale of 1 – 10 (1 being the lowest, 10 being the highest) she rated the pain 6 –

7. The patient does perineal care on her own. This can help her condition

improve, the patient verbalizes.

3.2 Nutritional – Metabolic Pattern

The patient loves to eat chicken and fish, she seldom eats pork. She often

drinks water. The patient is not choosy when it comes to eating. She is taking

vitamins that she verbalized.

3.3 Elimination Pattern

Fourth degree perineal laceration greatly affects the patient’s elimination

pattern. The patient verbalized pain upon urinating which leads her to seldom

urinate. At the moment of assessment, she has no had her bowel movement yet

but as the days past she had her bowel movement and verbalizes no pain upon

doing so. The patient did not use any assistive devices.

3.4 Activity – Exercise

Upon entering the patient’s room for the first time, the patient was not

there. The patient was in the nursery to see her baby. Even before the post partum

period, the patient does walking as a form of exercise. Fourth degree perineal

laceration doesn’t prevent the patient to do walking.

3.5 Cognitive Perceptual Pattern

The patient does not have any sensory perception deficits. The patient is

without eyeglasses and can read.

3.6 Sleep – Rest Pattern

The patient did not verbalize any sleeping problem and assures herself that

she sleeps at least 8 hours a day. The patient does not usually take naps. She

sleeps as early as 9pm and wakes up as early as 6am. Sometimes, she sleeps late if

there are still some things that should be done.

3.7 Self- Perception Pattern

The patient describes herself as a simple person. The main concern of the

patient is the fast healing of her perineal laceration so that she can go home

already.

3.8 Role – Relationship Pattern

The patient lives with her mother. The patient has wanted to have her own

house since then. Mrs. Latoy, Catherine verbalized that like any other

houses/homes, conflict can never be neglected in their hose. Every time conflict

comes, the patient just prays for it.

3.9 Sexuality – Reproductive Pattern

Due to pregnancy, the patient’s sexual relationship with the husband

lessened because of the fear that something wrong might happen to the baby

inside her womb.

3.10 Coping Stress Management Pattern

With money matters, both the husband and the patient make the decision.

When stress confronts the patient, the patient prays for it and thinks some possible
 solutions to surpass it. The patient expects the nurses and student nurses to help

her attain fast healing of her condition.

3.11 Value – Belief System

The patient finds strength through God and family. As a Roman Catholic, the

patient feels that going to Church every Sundays is important. Even during

pregnant state, the patient never failed to attend Sunday masses.

4. PATHOPHYSIOLOGY AND RATIONALE

4.1 The Normal Anatomy and Physiology of Organ / System Affected

Ovaries
Ovaries are approximately 4cm long by 2cm in diameter and of
approximately 1.5cm thick or the size and shape of almonds. They are grayish-
white and appear pitted on the surface. An unruptured, glistening clear, fluid-
filled graafian follicle or a miniature yellow corpus luteum (the structure left after
the ovum has been discharged often can be observed on the surface of the ovary.
Its function is to produce mature and discharge egg cells. In the process, the
ovaries produce estrogen and progesterone and initiate and regulate menstrual
cycles. With pregnancy, ovulation stops because of the feedback mechanism of
estrogen and progesterone produced by the corpus luteum early in pregnancy and
the placenta later in pregnancy. This feedback causes the pituitary gland to halt
production of FSH and LH without stimulation from these, ovulation will not
occur.

Uterus

It is as big as medium-sized pear. It is oriented in the pelvic cavity with

the larger, rounded part directed superiorly. With maturity, a uterus is
approximately 5-7cm long, 5cm wide. It weighs about 60g in a non-pregnant
state. Its function is to receive the ovum from the fallopian tube, providing peace
for implantation and nourishment during fetal growth, furnish protection to a
growing fetus and at maturity of the fetus, expel it from the body. During
pregnancy, its most obvious change is the increase in size in order to
accommodate the growing fetus. This growth is partly because of the formation of
a few muscle fibers in urine myometrium. By the end of pregnancy, muscle fibers
in the uterus are 2-7 times longer than before pregnancy. Because uterine fibers
only stretch during pregnancy, uterus is able to return to its pregnancy state.

Cervix

It a part of uterus located above the vagina; the narrow part of the uterus.
It becomes more vascular and edematous during pregnancy in response to the
increased level of circulating estrogen from placenta.It softens in consistency due
to increased fluid between cells. It darkens from a pale pink to violet because of
increased vascularity. A tenacious coating of mucus fills the cervical canal, which
acts to seal out bacteria during pregnancy and thus help prevent infection in the
fetus and membranes.

Vagina
 It is a hollow musculomembranous canal located posterior to the bladder
and anterior to the rectum. It extends from the cervix of the uterus to the external
vulva. Its function is to act as the organ of intercourse and to convey sperm to the
cervix so sperm can meet with the ovum in the fallopian tube. With child birth, it
expands to serve as the birth canal.

Fourchette

It is the ridge of tissue formed by the posterior joining of the two labia
minora nad the labia majora. This is the structure that is sometime cut
(episiotomy) during childbirth to enlarge the vaginal opening.

Perineum/ Perineal Body

Posterior to the fourchette is the perineal body or perineum. Because this

is a muscular area, it is easily stretched during childbirth to allow enlargement of
the vagina and passage of the fetal head.

The median raphe of the levator ani, which is positioned between the anus
and vagina, is reinforced by the central tendon of the perineum on which canverge
the bulbocavernosus muscles, the superficial transverse perineal muscles and the
external anal sphincter.

Anus

Anal tissues are normally moist and hairless compared with perineal skin.
The tissue is coarser and more darkly pigmented. The anus is held closed by the
voluntary external muscle sphincter. The anus is the passage way of feces during
bowel movement.

Mammary Glands
 These are the organs for milk production and are located in the breasts. A
rise in estrogen at puberty produces a marked increased in size from increased
connective tissue and deposition of fat in girls and a transient increase in boys. Its
glandular tissue is necessary for successful breast-feeding, remains undeveloped
until a first pregnancy begins. During pregnancy, she experiences a feeling of
fullness, tenderness or tingling in her breasts because of the increased stimulation
of breast tissue high estrogen level in the body. As pregnancy progresses, breast
size increases because of hyperplasia of mammary alveoli and fat deposits. Early
in pregnancy, breast begins readying themselves for the secretion of milk. And of
the 16th week, colostrum, the thin, watery, high-protein fluid that is the precursor
of breast milk, can be expelled from nipples.

DIAGRAM OF THE ORGAN AFFECTED

4.2 Schematic Drawing

SPERM EGG

Fertilization

Zygote migrates 3-4 days to the uterus

Mitotic cell division:

Morula

Blastocyst

Implantation

Trophoblast cells secretes HCG

Corpus luteum secret estrogen & progesterone

Suppress menstruation

Trophoblast

EMBRYO

FETUS

CONCEPTUS
4.3 Disease Process

Each month, in one of a woman's two ovaries, a group of immature eggs

start to develop in small fluid-filled cysts called follicles. Normally, one of the

follicles is selected to complete development (maturation). This "dominant

follicle" suppresses the growth of all of the other follicles, which stop growing

and degenerate. The mature follicle ruptures and releases the egg from the ovary

(ovulation). Ovulation generally occurs about two weeks before a woman's next

menstrual period begins.

After ovulation, the ruptured follicle develops into a structure called the

corpus luteum, which secretes two hormones, progesterone and estrogen. The

progesterone helps prepare the endometrium (lining of the uterus) for the embryo

to implant by thickening it.

The egg is released and travels into the fallopian tube where it remains

until a single sperm penetrates it during fertilization (the union of egg and sperm;

see below). The egg can be fertilized for about 24 hours after ovulation. On

average, ovulation and fertilization occurs about two weeks after your last

menstrual period.

If sperm does meet and penetrate a mature egg after ovulation, it will

fertilize it. When the sperm penetrates the egg, changes occur in the protein

coating around it to prevent other sperm from entering. At the moment of

fertilization, your baby's genetic make-up is complete, including its sex. Since the

mother can provide only X chromosomes (she's XX), if a Y sperm fertilizes the

egg, your baby will be a boy (XY); if an X sperm fertilizes the egg, your baby

will be a girl (XX).

Within 24-hours after fertilization, the egg begins dividing rapidly into

many cells. It remains in the fallopian tube for about three days. The fertilized egg

(called a zygote) continues to divide as it passes slowly through the fallopian tube

to the uterus where its next job is to attach to the endometrium (a process called

implantation). First the zygote becomes a solid ball of cells, then it becomes a

hollow ball of cells called a blastocyst. Before implantation, the blastocyst breaks

out of its protective covering. When the blastocyst establishes contact with the

endometrium, an exchange of hormones helps the blastocyst attach. Some women

notice spotting (or slight bleeding) for one or two days around the time of

implantation. The endometrium becomes thicker and the cervix is sealed by a

plug of mucus.

Within three weeks, the blastocyst cells begin to grow as clumps of cells

within that little ball, and the baby's first nerve cells have already formed. Your

developing baby is called an embryo from the moment of conception to the eighth

week of pregnancy. After the eighth week and until the moment of birth, your

developing baby is called a fetus.

 Human Chorionic Gonadotrophin (hCG) is a hormone present in your

blood from the time of conception and is produced by the cells that form the

placenta. This is the hormone detected in a pregnancy test; but, it usually takes

three to four weeks from the first day of your last period for the levels of hCG to

be high enough to be detected by pregnancy tests. The development stages of

pregnancy are called trimesters, or three-month periods, because of the distinct

changes that occur in each stage

During labor the perineum will be incised and it is called episiotomy.

Median episiotomy commonly causes fourth degree laceration.

When one reflects that the principal effectiveness of the puboccoccygeus

and levator ani is exerted posterior to the rectum, where their fusion forms the

levator plate, it is evident that a laceration through the anterior rectum, perineal

body, and posterior vagina is not likely to have been due to forces simultaneously

exerted to a point of overstretching the major sources of uterine support. Though

the injury disrupted the anal sphincter many of the patients will, by vigorously

exercising the pubococcygeus over a long period of time, produce an actual

hypertrophy which results in a side-to-side sphincter like action which helps hold

the sides of the fistula in opposition, and accomplishes a semblance of anal

continence.

Other factors that contributes to perineal laceration are: Lithotomy

position during labor, large infants over 9 pounds, precipitated labor,

primigravida, and old age.

4.4 CLASSICAL AND CLINICAL SYMPTOMS

Classical Symptoms Clinical Symptoms Rationale

1. Perineal Pain -manifested. An episiotomy can cause
The patient feels a burn-like considerable discomfort
pain in her perineum because the perineum is an
especially during voiding. extremely tender area. Most
women expect labor to be
painful. However, they usually
do not anticipate the pulling
pain from perineal stitches in
the postpartal period.
Source:
Maternal and Child Health
Nursing 4th edition by Adele
Pillitteri
2. Dyspareunia -manifested It can occur due to
The patient anticipated pain impaired skin integrity and/or
f ever they wil plan to have abnormal placement of tissue,
coitus this time. vaginal infection or hormonal
changes.
Source:
Maternal and Child Health
Nursing 4th edition by Adele
Pillitteri
3. Urinary Incontinence -not manifested This may be due to wrong
4. Fecal Incontinence - not manifested positioning of the tissue
during repair.
Source:
Maternal and Child Health
Nursing 4th edition by Adele
Pillitteri
5. extreme tiredness (fatigue) manifested - a woman is generally tired
- patient was fatigue after from labor processes
giving birth
Source: Maternal & Child
Health Ng., 4th edition by
Adele Pilliteri, p.487
6. constipation manifested - the gastrointestinal system
- pt. not able to void after first becomes fairly inactive during
24 hours from delivery labor. This is probably due to
the shunting of blood to non
life-sustaining organs and also
to pressure on stomach &
intensive from the contracting
uterus
 Source: Maternal & Child
Health Ng., 4th edition Adele
Pilliteri, p. 487
7. diarrhea not manifested - some women experience a
loose bowel movement as
contractions grow strong

Source: Maternal & Child

Health Ng., 4th edition by
Adele Pilliteri p. 487

IV. NURSING INTERVENTION

1. Care guide of patient with disease condition

A. Provide Pain Relief

Pain fro sutured perineum can be intense especially when applying force

(the pulling pain from perineal stitches). Pain intervention should be done to

reduce pain. Analgesic such as Ibuprofen is highly recommended for relieving

pain. Warm sitz bath can provide comfort beyond the immediate postpartum care.

B. Promote Perineal Care

Every woman needs attention to perineal cleanliness in the post partal

period to prevent infection. Interruption in skin integrity from an episiotmy also

increases the client’s risk for infection.

C. Encourage Perineal Exercises

Some women find that carrying out perineal exercises three or four times a

day greatly relieves episiotomy discomfort. The exercise consists of contracting

and relaxing the muscles of perineum five to ten times in succession as if trying to

top voiding (Kegel’s exercise). This improves circulation to the area and so helps

decrease edema.

D. Administer Cold and Hot Therapy

Applying an ice bag or cold pack to the perineum during the first 24 hours

reduces perineal edema and the possibility of hematoma formation, and therefore

reduces pain and promotes healing and comfort. After this time, healing increases
 best, if circulation to the area is encouraged by the use of heat. Dry heat in the

form of a perineal hot pack or moist heat with a sitz bath is an effective way of

increasing circulation to the perineum, providing comfort, reducing edema, and

promoting healing.

E. Relieve Muscular Aches

The mother may need a mild analgesic such as acetaminophen (Tylenol)

for the pain. A backrub is effective for relieving aching shoulders or back.

F. Enhance Family Functioning and Bonding

Expand mother’s self-esteem and allowing her to view herself as a new

mother and her new infant as a member of their family. Teaching new mothers is

important, but it is also important to explore what they already understand about

child care and what they believe would be a sensible solution to a problem.

2. Actual Patient Care

2.1 Brunswick Lens Model (PowerPoint)

2.2 NURSING CARE PLAN

PATIENT’S NAME: Mrs. Latoy, Catherine Paquibot SEX: Female

AGE: 28 years old ROOM #: OB 4
NURSING CARE PLAN
 NEEDS / SCIENTIFIC OBJECTIVE
NURSING NURSING
PROBLEMS BASIS / OF RATIONALE
DIAGNOSIS SIGNIFICANCE ACTIONS
CUES CARE
I. Physiologic Measures to lessen
Overload pain:
Pain 1. do perilite
Objective exposure - this helps faster
Cues: procedure as healing of suture.
-facial grimace ordered.
Post partum
-changes body
patients 2. elevate head of -position change
position bed at intervals.
manifest pain and gentle
frequently Turn client from
can be related massage may
-restlessmess side to side. relieve pain/
to reduced Provide back care
-irritability discomforts.
oxygen in and tissue
-burn-like pain
Altered tissues from massage.
during
comfort: acute impaired
urinating/ 3. encourage use
pain related to circulation, After 8 hours -redirects attention
voiding in the of relaxation promotes sense of
perineal pressure on of SN- patient techniques.
sutured part control.
laceration. tissue, external interaction, the
and stops once
injury or patient will be 4. administer cold -reduces perineal
done voiding. & hot therapy.
overstretching able to: hematoma &
-Istan is
of body 1. report pain edema. Therfore
ordered for her reduces pain and
cavities with at a tolerable
to be taken promotes healing
fluid or air. level.
every 6 hours and comfort.
5. administer sitz - decreases
for 4 doses. bath.
Source: inflammation by
Maternal & vasodilation.
Subjective Therefore, reduces
Child Health
Cues: pain & promotes
Nursing by
“sakit akong healing.
Pillitteri 4th 6. make time to -helpful in
tahi day uy, listen to and
edition, page alleviating anxiety
kung mangihi maintain frequent
114. and refocusing of
ko, mawawa contact with attention.
raman sad ig patient.
human mura
7. provide pain - medicine should
siyag hapdos.” relief medication be taken to relieve
As verbalized as ordered by pain.
by Mrs. Latoy. physician.
PATIENT’S NAME: Mrs. Latoy, Catherine Paquibot SEX:
SOURCE: Female
Maternal and Child Health
AGE: 28 years old ROOM
Nursing th
#: OB
4 edition 4
by Pillitteri
NURSING CARE PLAN
 NEEDS / SCIENTIFIC OBJECTIVE
NURSING NURSING
PROBLEMS BASIS / OF RATIONALE
DIAGNOSIS SIGNIFICANCE CARE ACTIONS
CUES
Perineal Measures to hasten
II. lacerations are wound healing:
Psychological sutured and
deficit 1. practice/ instruct -reduces risk of
treated as an good handwashing spread of bacteria.
A. Altered episiotomy and aseptic wound
Skin Integrity repair. Make care. Encourage/
provide perineal
certain that the care.
Objective degree of the
Cues: laceration is 2. inspect incision. -provides early
-fourth degree Note characteristics detection of
documented, of drainage from developing
perineal because wound. infectious process,
laceration due afterward it is and/or monitors
to giving birth resolution of
often difficult preexisting
to a 3.55 Impaired Skin to distinguish a peritonitis.
kilograms Integity: fourth repaired 2. demonstrate 3. monitor vital -suggestive presence
baby. degree perineal perineal behaviors/ signs especially of infection/
-has suture on laceration laceration from temperature. developing sepsis,
techniques to
her genitalia related to an episiotomy abscess, peritonitis
promote
(perineum to episiotomy. repair on healing/
rectum) inspection. 4. encourage -reduces pressure on
prevent
-post partum Lacerations wearing of loose compromised
complication. fitting/ tissues, which may
mother tend to heal nonconstrictive improve
-bleeding noted more slowly clothing. circulation/healing
(lochial because the
discharge) 5.explain the -perinal pads can be
edges of the importance of a bed for bacterial
suture line are changing the growth.
Subjective ragged. perineal pads.
Cues:
6. encourage diet -these will help
“Lageh day, Source: high in protein and patient resist
nagisi lageh. Maternal & vitamin C. infection. Mother’s
Taas man daw Child Health body need s to be
healthy to fight
ingon ang Nursing by foreign bodies.
doctor.” As Pillitteri 4th
verbalized by edition, page 7. administer -to treat specific
700. antibiotic as infection and
Mrs. Latoy. indicated. enhance healing.

SOURCE: Nursing Care Plan by Murr

7th edition.
PATIENT’S NAME: Mrs. Latoy, Catherine Paquibot SEX: Female
AGE: 28 years old ROOM #: OB 4
NURSING CARE PLAN
 NEEDS / SCIENTIFIC OBJECTIVE
NURSING NURSING
PROBLEMS BASIS / OF RATIONALE
DIAGNOSIS SIGNIFICANCE CARE ACTIONS
CUES

Measures to
increase urine
output:

1. encourage fluid -to help maintain

II. Physiologic intake upto 3000 renal function.
deficit or more ml per
B. Altered day.
Elimination
2. encourage -open expression
client to verbalize allows client to
Objective Laceration can concerns/fears. deal with feelings
Cues: Altered cause pain on and begin problem
- hesitant to Urinary elimination solving.
void Elimination: pattern. The
-Dysuria Hesitancy to suture is not 3. record urinary -sudden decrease
output, investigate in urine flow may
- Urone output void related to fully healed yet sudden reduction/ indicate
is less than pain upon causing pain 3. void at least cessation of urine dehydration.
normal per urinating when exerting 240 ml of urine flow.
shift secondary to force. at the end of -stimulate
- fourth degree perineal the shift. 4. establish awareness,
bladder training enhances
perineal laceration. Source: program. Promote regulation of body
laceration. Fundamentals client participation function and helps
of Nursing 5th to level of ability. to void accidents.
Subjective edition bi
Cues: Potter and 5. stimulate -promotes
bladder emptying urination by
”wa pa ko ka Perry. by running water, relaxing urinary
ihi day, karun pouring warm sphincter.
pa. sakit man water over
gud e-ihi.” As peritoneum.
verbalized by
6.emphasize -to reduce
Mrs. Latoy importance of infection/ skin
keeping area dry. breakdown.

7. promote -to reduce risk for

perineal care. infection.

SOURCE: Maternal and Child Health

PATIENT’S NAME: Mrs. Latoy, Catherine Paquibot SEX:4thFemale
Nursing edition by Pillitteri
AGE: 28 years old ROOM #: OB 4

SOAPIE#1
 S- “sakit akong tahi day uy, kung mangihi ko. Mawawa raman sad ig human, mura
siyag hapdos.” As verbalized by Mrs. Latoy.

O- patient is conscious; patient is without IVF; facial grimace; patient changed

body position frequently.

A- altered comfort: acute pain related to fourth degree perineal laceration.

P- to report pain at a tolerable level.

I-
done perilite exposure as ordered; elevated head of bed at intervals and turned
patient from side to side; encouraged use of relaxation techniques;
administered cold & hot therapy; administered sitz bath; made time to listen to
and maintain frequent contact with patient; provided pain relief medication as
ordered by physician.

E- the patient reported pain at a tolerable level.

PATIENT’S NAME: Mrs. Latoy, Catherine Paquibot SEX: Female

AGE: 28 years old ROOM #: OB 4
 SOAPIE#2

S- ”wa pa ko ka ihi day, karun pa. Sakit man gud e-ihi.” as verbalized by Mrs.
Latoy.

O- received patient lying on bed; patient was conscious; patient had no IVF; urine
output of the patient was less than normal per shift; patient was hesitant to
void.

A- altered urinary elimination: hesitancy to void related to pain upon

urinating secondary to perineal laceration.

P- to void at least 240ml of urine at the end of the shift.

I-
encouraged fluid intake upto 3000 or more ml per day; encouraged client to
verbalize concerns/fears; recorded urinary output, investigate sudden
reduction/ cessation of urine flow; established bladder training program.
Promote client participation to level of ability.; stimulated bladder emptying
by running water, pouring warm water over peritoneum; emphasized

E-
importance of keeping area dry; promoted perineal care.

the patient voided at least 240 milliliter of urine at the end of the shift.

PATIENT’S NAME: Mrs. Latoy, Catherine SEX: Female

AGE: 28 years old ROOM #:OB 4

HEALTH TEACHING PLAN

OBJECTIVES CONTENT METHODOLOGY EVALUATION
 General:
After 2 days of
student nurse-
patient and
significant others
interaction, patient
and significant
others will be able
to acquire adequate
knowledge, attitude
and skills in the
need of the
postpartum patient
with Physiologic
deficit.
Specific:
After 45 minutes
of student nurse-
patient and
significant others
interaction, patient
and significant
others will be able
to:

1. define lochial • Definition of term: Informal Discussion Patient showed

discharge and its Lochial discharge or interest by looking
normal outcome. lochia is a uterine at the student nurse
flow, consisting of keenly and nodding
blood, fragments of for sometime.
deciduas, white blood
cells, mucus and some
bacteria. This occurs
within three weeks.

NORMAL
OUTCOME:
-Lochia rubra= red (1-
3days)
-Lochia serosa= pin
(3-10 days)
-Lochia alba= white
(10-14 days or 3
weeks).
2. demonstrate the • Ways to hold baby Demonstration and The patient
different ways to during Return showed cooperation
breastfeed a baby and breastfeeding: Demonstration. by repeating what
burping positions. -cradle hold the student nurse
-football hold had done.
-side lying
-tailor’s position or
across lap.
3. state the advantages
of breastfeeding Advantages of Informal Patient listened
breastfeeding: Discussion and looked at the
Best for babies student nurse
Reduce incidence of keenly.
allergies
Economical
Antibodies
Stool inoffensive
Temperature always
idea;
Fresh milk
• Emotional bonding
b/w child and
mother
• Easy once
established
• Digested easily
• Immediately
available
• Nutritionally
optimal
• Gastroenteritis
greatly reduced
4. perform cord
dressing Steps in cord Demonstration and
The patient nod
return
dressing: for sometime and
demonstration
• Cord should be kept tried following the
until it drops off by steps being done by
itself. the student nurse.
• Apply alcohol on
the cord area once/
twice.
• Prepare six cotton
pledgets and a
alcohol.
1st cotton pledget:
- base of the
cord
 - clean it with
circular motion
starting from inner to
outer or you can do
the sunrays method
2nd cotton pledget:
- sides of the
cord starting down,
going up.
3rd cotton pledget:
- clean the base
of the clamp.
4th cotton pledget:
- clean the sides
of the clamp.
5th cotton pledget:
- clean the cord
again. This time,
clean it from upper to
base.

6th cotton pledget:

- clean the base
again with the same
principle.
5. state the importance • Importance of Informal Discussion The patient
of perineal care. perineal care: listened carefully and
- to promote relates the importance
comfort and to her daily activities.
well-being.
- To minimize
offensive odor.
- To promote
personal
hygiene.
- To avoid
infection.

PATIENT’S NAME: Mrs. Latoy, Catherine SEX: Female

AGE: 28 years old ROOM #: OB 4

DRUG THERAPEUTIC RECORD

Drug/Dose Classifications/ Indications/ Principle of Treatment Evaluation
/Frequency Mechanism of contraindications/ Care
/Route Action adverse effects
* Lilac 15 cc Laxative I: constipation, - Use - Ensure The patient
every sleeping -contains lactulose. treatment of hepatic cautiously to adequate reported a
hours P.O The bacterial encephalopathy lactose hydration. very soft
degradation of CI: low galactose diet intolerance, - Explain stool during
lactulose resulting and intestinal DM patient. purpose of
defecating.
in an acidic pH obstruction. the drug.
inhibits the AR: abdominal - Let patient
diffusion of NH3 discomfort associated drink lots of
into the blood by with flatulence. water.
causing the Prolonged use or - Administer
conversion of NH3 large dose may result IVF as
to NH4+ also in diarrhea with ordered by
enhances the excessive loss of the physician.
diffusion of NH3 water and electrolyte.
from the blood into
the gut. Produces
an osmotic effect in
the colon with
resultant distention
promoting
peristalsis.
* Oxytocics I: to prevent and treat - Store tablets - Explain use The patient’s
methylergono - Increases motor post partum in tightly of drug to
vine maleate activity of the hemorrhage caused closed, light patient. bleeding
(Methergine) 1 uterus by direct by uterine atony or resistant -Tell patient
ampule deep stimulation of the subinvolution. container. to report lessen.
IM now smooth muscle, CI: pregnant patients, - Discard if adverse
(11:10 AM) shortening the 3rd patient sensitive to discolored reactions
stage of labor and ergot preparations -Dilute to promptly.
reducing blood and in patient with 5ml with - Ensure
loss. hypertension or NSS, P.R.N adequate
toxemia. -Give slowly hydration.
AE: seizures, stroke over at least - Raise side
with IV use, 1 minute rails
dizziness, headache, while - Assist
nausea and vomiting, carefully patient ADL.
hallucination, monitoring
hypertension, BP.
diarrhea, hematuria, -Store
dyspnea, leg cramps solution
below 8
degrees
Celsius.
PATIENT’S NAME: Mrs. Latoy, Catherine SEX: Female
AGE: 28 years old ROOM #: OB 4
 DRUG THERAPEUTIC RECORD
Drug/Dose Classifications/ Indications/ Principle of Treatment Evaluation
Frequency Mechanism of contraindications/ Care
/Route Action adverse effects
* Istan 500 Nonsteroidal I: headache, -should be - increase Patient
mg; cap Anti- muscular & taken with fluid intake reported a
every 6 hours inflammatory traumatic pain, post food. - raise side more
(4 doses) Drug partum pain, relief rails tolerable
3pm-4am- -contains of primary -Let patient pain.
10am-4pm Mefenamic acid. dysmenorrhea. have her
Binds the CI: Peptic/ meal before
prostaglandin intestinal giving the
synthetase ulceration, drug.
receptors COx-1 inflammatory - assist
and Cox-2 bowel disease, patients
inhibiting the renal/ hepatic ADL
action of impairment. -proper skin
prostaglandin AE: GI care for the
synthetase. As disturbances & patient.
these receptor bleeding, diarrhea,
have a role as a peptic ulceration,
major mediator of dizziness, skin
inflammation rashes,
and/or a role for nephropathy.
prostanoid
signaling in
activity-
depending
plasticity. The
symptoms of pain
are temporarily
reduced.

PATIENT’S NAME: Mrs. Latoy, Catherine SEX: Female

AGE: 28 years old ROOM #: OB 4

DRUG THERAPEUTIC RECORD

Drug/Dose/ Classifications/ Indications/ Principle of Treatment Evaluation
Frequency Mechanism of contraindications/ Care
/Route Action adverse effects
* Aldrid 500mg Penicillin I: Respiratory tract - monitor drug -do skin Patient
IVTT every 6 (antibiotic) infection, GIT, GUT, levels. testing verbalized soft
hours -Inhibits formation skin, soft tissue and - monitor for - explain stool during
(8am-2pm-8am- of bacterial cell other infections. signs of drug purpose of bowel
2pm) wall. CI: Hypersensitivity to toxicity drug. movement, this
penicillins and -use may be related
cephalosporins. combination to the GI
AE: GI disturbances, with extreme disturbance
allergic reactions, caution. effect of the
anaphylaxis, blood drug.
disorders,
superinfections.
* Co-Amoxiclav Penicillin AE: upset stomach, -take - ensure Patient
625mg 1 tab BID (antibiotic) diarrhea medication adequate verbalized soft
(9am-7pm) -inhibits formation I: patient with infection, exactly as hydration. stool during
of bacterial cell sinusitis, otitis media, prescribed. -explain the bowel
wall by blocking tonsillitis, childbirth, -take at purpose of movement this
cross-linking of the abortion, dental regular drug. may be due to
cell wall structure. abscesses intervals and -assist the drugs
complete the patient diarrheal effect.
prescribed ADL.
course. -raise side
-it may stain rails
your teeth if
taken by
liquid.
-oral
contraceptive
may lessen
drug effect
* Triconex 500mg Antibiotic I: intestinal & hepatic - should be -let patient The patient had
1 tab TID P.O - contains amoebasis, urogenital taken on an be aware of no signs of
(8A-1P-6A) metronidazole trichomoniasis, empty the metallic infection.
which enters nonspecific vaginitis, stomach if taste of the
anaerobic giardiasis. suspension. drug.
bacterium where, CI: hypersensitivity to - it tablet, take - ensure
via the electron imidazoles, patient with with food. adequate
transport protein active neurological -discontinue if hydration
ferroxidin, it is disorders or history of CNS -proper skin
reduced. The drug blood dysgrasias, symptoms care for the
then binds to DNA, hypothyroidism, 1st occur. patient.
and DNA breakage trimester of pregnancy. -take drug -raise side
occur. AR: metallic taste, even when rails
nausea and vomiting, you feel well. Assist
headache and skin patient’s
problems ADL
PATIENT’S NAME: Mrs. Latoy, Catherine SEX: Female
AGE: 28 years old ROOM #: OB 4

DRUG THERAPEUTIC RECORD

Drug/Dose/ Classifications/ Indications/ Principle of Treatment Evaluation
Frequency Mechanism of contraindications/ Care
/Route Action adverse effects
* Oxytocin 10 Oxytocics I: to induce or - never give - ensure - Patient
units to IVF - causes potent stimulate labor, to drug adequate had a
(10:42 am) and selective reduce postpartum simultaneously hydration. normal
stimulation of bleeding after by more than - explain delivery
uterine and expulsion of one route. use of despite her
mammary placenta; - drug does not drug to big baby.
gland smooth incomplete/ cause fetal patiebt.
muscle. inevitable abortion. abnormalities - tell
CI: when used as patient to
hypersensitivity to indicated. report
drug, when vaginal -dilute drug by adverse
delivery is not adding 10 reaction
advised, when units to 1 liter promptly.
CPD is present, NSLR, D5W Check
patient with solution. perineal
hypertonic uterine - don’t give pad
pattern. bolus - monitor
AE: subarachnoid injection. vital signs
hemorrhage, Use an
hypertension, infusion pump.
nausea and
vomiting,
abruption
placentae, post
partum
hemorrhage,
uterine rupture,
pelvic hematoma.
PATIENT’S NAME: Mrs. Latoy, Catherine SEX: Female
AGE: 28 years old ROOM #: OB 4

DRUG THERAPEUTIC RECORD

Drug/Dose/ Classifications/ Indications/ Principle of Treatment Evaluation
Frequency Mechanism of contraindications/ Care
/Route Action adverse effects
* Misoprostol Antacids, I: Benign gastric - should be - increase The
2 tabs per Antireflux and duodenal taken with fluid intake. patient had
rectum NOW. Agents & ulceration, NSAID- food. - tell patient flatulence
(11:12 am) Antiulcerants/ associated to report which
drug acting on ulceration, any shows a
the uterus. surgiacal bleeding. good sign
- it seems to termination of Raise side and
inhibit the acid pregnancy. rails reported a
secretion by a CI: women of child -let patient soft stool
direct action on bearing potential; rest. during
the parietal pregnancy & - assist bowel
cells. The lactation. patient movement.
inhibition of AR: diarrhea, activity of
adenylate abdominal pain, daily living.
cyclase may be dyspnea,
dependent on constipation,
guanosin-5- flatulence, nausea
triphosphate and vomiting,
(GTP). abnormal bleeding,
Considerable cramps and
decrease in the headache.
volume and
pepsin content
of the gastric
secretion.
PATIENT’S NAME: Mrs. Latoy, Catherine SEX: Female
AGE: 28 years old ROOM #: OB 4
BRING HOME MEDICATION
DRUG THERAPEUTIC RECORD
Drug/Dose/ Classifications/ Indications/ Principle of Treatment Evaluation
Frequency Mechanism of contraindications/ Care
/Route Action adverse effects
*Natravox Penicillins I: Respiratory - monitor - provide The patient
625mg 1 tab - Inhibits tract, GUT, renal proper skin will not show
BID for 5 formation of abdominal, skin function. care any signs of
days bacterial cell & soft tissue - should not - ensure infection.
(8am-6pm) wall by infections. be taken adequate
blocking cross- CI: with another hydration
linking of cell- hypersensitivity penicillin - explain the
wall structure. to penicillin. -store in a purpose of
History of dry place the drug.
Amoxicillin-K less than 25 - ask patient
clavulanate- degrees to eat before
associated Celsius. taking the
cholestatic - should be drug.
jaundice/ hepatic taken with
dysfunction. food.
SE: transient
hepatitis and
cholestatic
jaundice, skin
rashes diarrhea,
nausea and
vomiting.
* Beniforte 1 Vitamins & I: treatment of -one cap - tell patient Patients
cap BID for 2 Minerals (pre nutritional daily the purpose RBCs are
months & post Natal) anemia due to - should be of the drug. expected to
(8am- 6pm) Antianemics iron, vitamin B12 taken on an - monitor increase.
- use to treat and folic acid empty vital signs.
anemia. deficiency. stomach - ensure
SE: constipation, adequate
black and plasty hydration.
stool, gastric
distress, pains,
less commonly
diarrhea.
V. EVALUATION AND RECOMMENDATION

Prognosis

Based on the patient’s assessment, the patient was experiencing acute pain related

to her fouth degree perineal laceration. Despite this, she prefers not to remain in bed. She

walks as a form of exercise. She does her own perineal car. The patient complies with

other treatment, medications and management regimen instructed by the doctor and

nurses. All these signs shows that the patient will recover from her condition faster than

expected.

Recommendation

The most important goal for the patient who underwent fourth degree perineal

laceration is to achieve full recovery and rule out the possible occurrence of infection.

Below are listed recommendations for the patient:

1. Compliance and maintenance of the medications prescribed by the physician.

2. A diet high in fluid and a stool softener.

3. No enema and rectal suppository.

4. No rectal temperature.

5. Promote good personal hygiene and giving importance to hand washing and perineal

care.

6. Deep breathing exercise if pain is felt.

7. Heat and cold application on the affected area.

8. Ambulation is encouraged.
9. Bed rest if the patient feels pain and fatigue.

10. Patient must be restricted to stressful activities.

11. Encourage adequate rest.

12. Abstain from alcohol and after recovery

13. Environmental sanitation

14. Follow up consultation or check up to her physician.

VI. EVALUATION AND IMPLICATION OF THE CASE STUDY TO:

Nursing Practice

Studying the case of Mrs. Latoy, Catherine gave the student nurse the opportunity

to enhance the student’s knowledge, attitude, and skills in rendering holistic therapeutic

nursing care for postpartum patients with the same complication as Mrs. Latoy’s. It has

furnished current ideas that focus on dedication to study.

This case study though not that perfect can aid as a foundation and reference for

the never-ending discovery for better interventions of students, professionals and family

of the affected individuals.

Nursing Education

This case study has been very useful in making the student understand the scope

of this condition. It facilitated the student nurse to relate the theories, discoveries and

other facts written in textbooks, to the actual situation. Through these observations,

students have attained new set of concepts which will be of great remedy in caring for

patients with the same condition.

Nursing Research

This case study can be utilized as reference for imminent research studies. This

will also furnish additional knowledge to the students for associating real life situations.
VII. REFERRAL AND FOLLOW-UP

After one week of discharge, the patient must see her physician for check-up.

VIII. BIBLIOGRAPHY

Benson, Ralph. Current Obstetric and Gynecologic Diagnosis and Treatment:

1976

Davis’ Gynecology and Obstetric Vol.1

Kazier, Barbara et. al. Fundamentals of Nursing Concepts, Process and Practice,
7th edition, Pearson Education Inc., 2004

MacDonald, Pritchard. Williams Obstetric; 17th edition.

Marieb, Elaine N. et. al. Essentials of Human Anatomy and Physiology, 6th
edition, Addison Wesley Longman Inc., 2000

Nettina, Sandra. The Lippincott Manual of Nursing Practice; 6th edition, Merrian
& Webster Bookstore, Inc.

Nicholas, David M.D. and Randall, Clyde M.D. Vaginal Surgery

Pilliteri, Adele. Maternal and Child Health Nursing; 4th edition, Lippincott
Williams and Wilkins

Potter, Patricia and Perri, Anne Griffin. Fundamentals of Nursing. 5th ed. St. Louis
, Missouri: Mosby 2005

http://www.aafp.org/afp/20031015/1585.html

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repair-of-the-perineum-FM-procedure.aspx