Saint Louis University

College of Nursing

FOOTLING BREECH
Presentation

A Case Study

A Case Presentation
Presented to the Faculty
Of the College of Nursing

In Partial Fulfillment
Of the Requirements for the Course
NCM 103

Submitted by:

BELMONTE, Mary Abigail

CORTEZ, Kristin Bernadette
ESBERTO, Helen
FAGYAN, Jones
OWEK, Yelloh Raiza
TIDACYAO, Gretsin

BSN III-E2

Submitted to:
Ma’am Katrina May Ramos, RN
Clinical Instructor

May 8, 2009
 NURSING ASSESSMENT

A. Patient’s Profile

Name: Espiloy, Deborah Valmonte

Age: 31 years old
Gender: Female
Civil Status: Married
Birthday: October 22, 1978
Birthplace: Bacnotan, La Union
Educational Attainment: High school graduate
Address: Calautit, Bacnotan La Union
Occupation: Housewife
Religion: Roman Catholic
Cultural Affiliation: Ilocano
Nationality: Filipino
Latest Hospitalization: No Previous Record
Admitting Physician: Helen H. Balagot
Attending Physician: Dr. Aguilar, Dr. Cababa, Dr. Escobar
Date and Time Admitted: May 4, 2010, 3:45am
Ward: OB-Gyne ward
Final Diagnosis: G4P3 (3013) PU 36 6/7 weeks AOG delivered by Cesarean section to live baby girl
Chief Complaint: Hypogastric pain

B. Present Illness

I. HEALTH HISTORY

History of Present Illness

One hour prior to admission, patient complained of a lumbosacral pain with associated uterine
contractions noted at 5-10 minutes interval, 60 seconds duration, mild to moderate in intensity with
associated bloody vaginal discharge. Persistence of symptoms prompted patient for consultation hence
the admission. She stated that her expected date of delivery that was revealed in the ultrasound is in
June 10-17, 2010.
Internal examination revealed that the patient’s baby is a footling-breech position, so patient
undergone a certain procedure which is cesarean section.

Past Medical History

Patient had no history of Hypertension, Diabetes Mellitus, asthma and PTB. There is no history of
surgery, accident and trauma. She has no allergies to food and drugs and she had been hospitalized
three times in ITRMC for delivery of her first two children and management of abortion in her second
pregnancy. She had a multiple gestation during her second pregnancy in which the developing fetuses
were aborted unwantedly in her third month of pregnancy.

Prenatal History

Patient is cognizant of pregnancy at 5 weeks AOG through amenorrhea from previous regular
menstrual cycle. Pregnancy test was done at home 12 weeks AOG revealing a positive result. She claims
that the pregnancy was unplanned but wanted without attempts of abortion. Subsequent prenatal check-
ups were done monthly until 28 weeks then, every two weeks until 36 weeks AOG and weekly thereafter.
Patient was prescribed with Calciumade 1 cap OD, Fumarade 1 tab OD. Quickening was felt last 6
months AOG. Ultrasound was first done in the OB clinic at 12 weeks AOG, which revealed a live singleton
intrauterine female fetus with good somatic and limbal activity. No exposure to viral exanthematous
diseases such as measles, chicken pox during the entire duration of pregnancy. No history of alcohol and
cigarette intake.

Family History
The patient has a family history of Diabetes Mellitus, Hypertension, asthma, Cardiovascular
Diseases, twinning and other congenital anomalies.

CAD DM HPN Cancer Asthma PTB Gastric Others

Ulcer
Father X √ √ Cancer of X X X X
side the
Bladder
Mother X √ √ Colon X X X X
side cancer

OB/Gynecologic History
A. Menstrual History
Menarche of the patient began when she was 12 years old in a regular cycle of 5-7 days.
She uses two packs of feminine napkins, moderately soaked in her whole menstrual cycle.
Patient sometimes experiences dysmenorrhea during her first to second days of her
menstruation. Patient is not yet in a menopausal stage.

B. Obstetric History
G1- 2005, LFT baby boy via NSD at ITRMC; no complications
G2 - 2006, LFT twins; spontaneous abortion
G3 - 2007, LFT baby boy via NSD at ITRMC; no complications
G4 - 2010, LFT baby girl via CS at ITRMC; no complications

C. Gynecological History
There were no previous surgical procedures done and previous gynecological problems
experienced by the patient. She does not experience any postcoital bleeding. She verbalized
that her vaginal discharges is whitish in color, not foul smelling and is just little in amount. She
doesn’t also experiences vaginal itching.

D. Contraceptive History
Patient and her husband don’t use artificial methods of contraception but verbalized that
they use Withdrawal method as their natural family planning method. They’ve agreed to the
method and use it ever since they got married.

E. Sexual History
First sexual intercourse happened when she was 25 years old. She claimed that her only
sexual partner was her husband. She and her husband are sexually active. There were no
sexually transmitted infections experienced by the patient.

Social and Environmental Background

The patient is a housewife living with her husband and children in their house with two rooms and
5 occupants. Source of water for drinking purposes comes from a commercial refilling station. Water for
domestic purposes comes from the deep well. Garbage is collected regularly. Patient is a non-smoker
and non alcoholic beverage drinker. Toilet is flush type and no history of travel.
 THIRTEEN AREAS OF ASSESSMENT

I. PSYCHOLOGICAL

The patient is a female, 31 y/o, married, Ilocano, a full time housewife and a mother to 3 children
in the family. She is Roman Catholic and stated that she doesn’t have any practices or beliefs that
would affect her health.
Patient stated that she enjoys her role as mother to her children and as wife to her husband;
organization was mentioned where she belongs; she mostly enjoys bonding with her family, and
watching TV as her activities.
II. MENTAL AND EMOTIONAL STATUS

During the interview, the patient is fully conscious, oriented to time, place and person. She is a
high school graduate; able to understand, comprehend and follow directions during the assessment.
She understand that she underwent caesarean section due to the findings during her internal
examination that her baby’s position is in footling breech position. This was her first time of
experiencing such major operation and the patient stated that as she reacted that her situation is
really difficult, especially that she is in pain.
Whenever the patient is stressed, or tired after doing her household chores the patient admitted
that she would just watch TV for her to relax. She admitted that as a mother and a wife, she fears of
losing her loved ones, especially that she has a history of losing their second baby which happened
to be twins at 3 months age of gestation, at year 2006. According to the patient, she was able to cope
and accepted everything after the said incident for about 3 months.
III. ENVIRONMENT STATUS

Due to the said condition of the patient, she has the risk of having infection, considering that there
is the presence of wound; abdominal binder is noted also. During assessment, she was observed
that she always guide the affected area and with minimal facial grimaces when moving is noted. No
side rails is noted when she was transferred to the ward for further monitoring and assessment.
IV. SENSORY STATUS

The patient doesn’t have any eye- related problems; she has good ability in distinguishing voice;
no problems in sense of taste; able to differentiate odors. At present, she has problem in sense of
feeling because of the pain she is experiencing. On the other hand, the patient has the good ability to
understand and initiate speech.
V. MOTOR STATUS

At present, the patient has limited movement and always possess guarding behaviour in the
abdominal area, especially when moving. When walking, moving, or sitting, the patient moves very
slowly; but able to move all extremities. When moving, the patient needs minimal assistance specially
when moving out from bed to go to the comfort room. The patient can still perform her common
activities of daily living, such as eating, combing of hair and breastfeeding her baby.
VI. NUTRITIONAL STATUS

The patient usually eats three times a day. Sample menu is rice, fish, hotdog, egg and vegetables.
She usually have her snacks such as fruits (oranges, banana) mostly in the morning. The patient has
a medium body built. She has smooth and warm to touch skin. No religious dietary restrictions that
was mentioned by the patient.
The patient is a good water drinker and does not prefer any soft drinks; patient admitted that she is
not measuring her everyday water intake She is not choosing any food to eat as long as she
believes that it is a nutritious food.
VII. ELIMINATION STATUS

The patient usually voids 5-8 times in a day, since she is a water drinker. Her regular bowel
movement is once a day, every morning. During hospital stay, she was not able to practice her
regular bowel movement.
VIII. FLUID AND ELECTROLYTE STATUS

The client eats three times a day, with good appetite and eats any type of food as she desired,
most especially fish and vegetables. There’s no contraindicated food for her before and during her
pregnancy.
She is a good drinker of water so amount is barely noted. Sometimes, she also drinks her milk
twice a day. She has a good skin turgor; with moist mucous membrane. During assessment, the
patient is taking mefenamic acid 500mg 1 tab, for her pain reliever and Coamoxiclav 6 mg x BID, as
anti-inflammatory,analgesic,and antipyretic.
Over all medications given to the patient were the following: Ketorolac 15 mg IV q 6 hours x 6
doses for her pain reliever; Nalbuphine 5 mg IV q 4 hours x 6 doses for her sedation before surgery,
and supplement to balance anesthesia; Ampicillin 2 mg IV q 6 hours for her antibiotic; Mefenamic
acid 500mg 1 tab and Coamoxiclav 6 mg x BID.
IX. CIRCULATORY STATUS

Patient’s regular pulse rate is ranging from 68- 90 BPM, +2, regular.
After the surgery, during assessment, pulse rate increased to 108 BPM.
Blood pressure is ranging from 130-110/80 mmHg, at left arm, lying.
X. TEMPERATURE STATUS

Patient’s body temperature is in normal limit, 36.6 °C, axillary.

XI. INTEGUMENTARY STATUS

Skin is warm to touch; with brownish skin color; with good capillary refill of 2-3 seconds.
Incision in the abdominal area is with intact dressing, not fully soaked with blood.
Normally, patient is perspiring due to weather.
Habits such as smoking, drinking alcohol beverages was denied by the client.

XII. COMFORT AND REST

Before hospital confinement, patient usually sleeps 9-10 in the evening and wakes up 6-6:30 in
the morning. The patient admitted that her sleep is only disturbed every time she wakes up to go to
the comfort room. During hospital stay, still the patient manifest sleep disturbance due to monitoring
of vital signs, and every time she breastfeeds her baby.
During assessment, the client is experiencing abdominal pain due to her condition, rated as 7 out
of 10, characterized as squeezing pain, radiating in the abdominal area, localized in the incision site,
aggravated when moving.
XIII. RESPIRATORY STATUS

Patient’s respiratory rate is from 20-22 cycles per minute in regular interval, no use of accessory
muscles noted; with absence of dryness in lips. She is acyanotic and does not experience difficulty
breathing.

Prioritized problem
1.Acute pain related to
surgical incision
2. Impaired skin integrity
related to tissue trauma
secondary to cesarean
section delivery
3. Sleep disturbance
related to multiple
factors (pain, time of
voiding, vital signs
taking)
4 .Risk for deficient fluid
volume related to blood
loss
5. Risk for infection
related to inadequate
primary defenses
NURSING DIAGNOSIS AND PRIORITIZATION
Prioritization
according to
Classification Justification
Maslow’s hierarchy
of need
Physiologic need Actual problem Acute pain is the 1st prioritized
problem according to Maslow’s
hierarchy of needs. It is the
primary problem since pain is
an actual problem, after
cesarean birth pain is intense
from the uterine or abdominal
incision that disturbs a person’s
normal functioning.
Avoidance allows the person to
be more comfortable active and
to assure a greater role in
directing the patient’s own care.
Physiologic need Actual problem Impaired skin integrity is the 2nd
prioritized problem.
Skin integrity is defined as
impaired altered epidermis and
dermis.
The skin serves as the primary
line of defense against bacterial
invasion. When skin is incised
for a surgical procedure the
important line of defense is loss.
Physiologic need Actual problem Sleep disturbs pattern is the
more explicit definition of
difficulty falling asleep or
staying asleep. It is the 3rd
prioritized problem because it
will provide sufficient energy to
perform activities of daily living,
it will enhance the client’s
feeling of well- being or
improving the quality the clients
sleep. It will reduce stress of the
patient.
Physiologic need Potential problem Risk for deficient fluid volume is
the 4th prioritized problem.
There is a deficient fluid volume
because of the blood loss from
surgery.
This is a risk wherein there is a
heavy bleeding for postpartum
woman.
Physiologic need Potential problem Risk for infection is the last
prioritized problem. At
increased risk for being invaded
by pathogenic organisms.
After cesarean birth is
performed hours after the
membrane ruptured a woman’s
risk for infection is higher.
 PATHOPHYSIOLOGY

PHYSIOLOGY OF PREGNANCY and CESAREAN DELIVERY IN

FOOTLING BREECH PRESENTATION
Release of FSH by
the anterior pituitary gland

Development of the graafian follicle

Production of estrogen (thickening

of the endometrium)

Release of the luteinizing hormone

Ovulation (release of mature ovum from

the graafian follicle)

Ovum travels into the fallopian tube

Fertilization (union of the ovum

and sperm in the ampulla)

Zygote travels from the fallopian tube

to the uterus

Implantation

Development of the fetus/embryo &

placental structure until full term

PRELIMINARY SIGNS OF LABOR

Lightening Braxton Hicks Contraction Ripening of the cervix

(descent of the fetal (false labor) (Goodell’s Sign wherein
head into the pelvis) >begin and remain irregular the cervix feels softer like
>1st felt abdominally consistency of the earlobe
>pain disappears with ambu-
lation
>do not increase in duration
and intensity
>do not achieve cervical
dilatation
 TRUE LABOR

Uterine Contractions SHOW Rupture of

Membranes
>increase in duration (pink-tinge of blood, (rupture of the amniotic sac)
and intensity a mixture of blood and fluid)
>1st felt at the back &
radiates to the abdomen
>pain is not relieved no
matter what the activity
>achieve cervical dila-
tation

Failed to progress labor

(due to footling breech presentation)

Breech presentation occurs in 3-4% of all deliveries. The

occurrence of breech presentation decreases with
advancing gestational age. Breech presentation occurs in
25% of births that occur before 28 weeks’ gestation, in 7% of
births that occur at 32 weeks, and 1-3% of births that occur
at term.

Predisposing factors
- Enlarged uterine cavity as in hydramnios and multiple
pregnancy.
increase risk for fetal distress
(meconium staining, hypoxia)

Increase risk of fetal death

Emergent cesarean delivery

(the incision made on the lower part of the abdomen)

Delivery of the fetus

Delivery of the placenta

 References:
A. Books
 Black, Joyce and Hawks, Jane - Medical-Surgical Nursing: Client Management for Possible
Outcomes, 7th Edition, 2005, Elsevier PTE Ltd., Singapore
 Black, Joyce and Hawks, Jane - Medical-Surgical Nursing: Client Management for Possible
Outcomes, 6th Edition, 2001, Philippines
 MIMS Annual Philippines, 19th Edition, 2007-2008
 Rosal Maria Isabel – PPD’s Nursing Drug Guide, 2nd Edition, 2007-2008
 Philippines Moms and Babies: A Health Guide Publication, 2000
 Doenges, Moorhouse, Murr – Nurse’s Pocket Guide, 11 th Edition, 2007
 Doenges, Moorhouse, Murr – Nurse’s Care Plans: Guidelines for Individualizing Patiet Care 6 th
Edition
 Porth, Carol M. – Pathophysiology: Concepts of Altered Health States 6 th Edition
 Suddarth, Brunner – Textbook of Medical Surgical Nursing 5th Edition
 Kozier, Erb, Berman, Snyder – Fundamentals of Nursing: Concepts, Process and Practice 7 th
Edition
 Dell, Bantam – The Bantam Medical Dictionary, 2004
 Tortora, Derrickson – Principles of Anatomy and Physiology 11 th Edition, 2006
 Karch, Amy M. – Lippincott’s Nursing Drug Guide, 2009