CHAPTER I

INTRODUCTION

Multiple gestation, or multiple pregnancy, occurs when two or

more fetuses are conceived at the same time in the same woman.
Common multiples are two and three, known as twins and triplets,
respectively. It can be differentiated from the term "multiple births"
because it refers to the conception of the fetuses, and may or may not
result in the live births of multiple babies.
Certain factors appear to increase the likelihood that a woman will
naturally conceive multiples. These includes mothers age: women over
35 are more likely to have multiples than younger women, family history
of

multiple

pregnancy

(genetics),

mothers

use

of fertility

drugs:

approximately 35% of pregnancies arising through the use of fertility

treatments such as IVF involve more than one child
Multiple gestation is risky for the mothers. Blood pressure ay get
too high resulting to pre-eclampsia, pregnancy induced hypertension
and/or toxemia. Mother is also at risk to develop gestational diabetes.
Having multiple pregnancy is more likely a risk to premature rupture of
membranes, pre-term labor, anemia and postpartum hemorrhage.
Because there are too many babies in the womb, mother might have
miscarriage.

Babies born from multiple-birth pregnancies are much

more likely to result in premature birth and SGA than those from single
pregnancies and that might also result to Cerebral Palsy. Multiples may
become monochorionic, sharing the same chorion, with resultant risk
of twin-to-twin transfusion syndrome. Monochorionic multiples may even
become monoamniotic, sharing the same amniotic sac, resulting in risk
of umbilical cord compression and entanglement. In very rare cases,
there may be conjoined twins, possibly impairing function of internal
organs. Multiple pregnancy often result to malpresentation of the fetuses.
Some of the managements of the multiple pregnancy are Another
procedure that the medical world is using today is known as selective
reduction, i.e. the termination of one or more, but not all, of the fetuses.
This is often done in pregnancies with multiple gestations to increase the
likelihood that one child may live a healthy life. Multiple pregnancy can
also be delivered either through normal spontaneous delivery or cesarean
section. Usually, in a twin pregnancy the first twin is in cephalic
presentation, planned Cesarean section does not significantly decrease
or

increase

the

risk

of fetal

or

neonatal

death or

serious

neonatal disability, as compared with planned vaginal delivery.

Malpresentation or fetal malpresentation is where the baby is in a
difficult position for the birth process. Breech is an example of a
malpresentation where the baby's bottom rather than its head is located
at the cervix. Face presentation is another malpresentation where the
baby's face comes out first during delivery rather than the crown of the

head. Malpresentation may increase the duration of labor or even

necessitate surgical intervention such as a cesarean
However, the general conditions that are thought to increase the
risk of malpresentation or malposition are abnormally increased or
decreased amount of amniotic fluid, tumour (abnormal tissue growth) in
the uterus preventing the spontaneous inversion of the fetus from breech
to vertex presentation during late pregnancy, abnormal shape of the
pelvis, laxity (slackness) of muscular layer in the walls of the uterus,
multiple pregnancy (more than one baby in the uterus), placenta previa.
Management for malpresentation is usually cesarean section.
A Caesarean section is a surgical procedure in which one or
more incisions are

made

through

mother's abdomen (laparotomy)

and uterus (hysterotomy) to deliver one or more babies, or, rarely, to

remove a dead fetus. A late-term abortion using Caesarean section
procedures

is

termed

a hysterotomy

abortion and

is

very

rarely

performed.
Caesarean

section

is

associated

with

risks

of

postoperative adhesions, incisional hernias (which may require surgical

correction) and wound infections. If a Caesarean is performed under
emergency situations, the risk of the surgery may be increased due to a
number of factors. The patient's stomach may not be empty, increasing
the anaesthesia risk. Other risks include severe blood loss (which may
require a blood transfusion) and postdural-puncture spinal headaches.

Complications from elective cesarean before 39 weeks include:

newborn mortality at 37 weeks may be 2.5 times the number at 40
weeks, and was elevated compared to 38 weeks of gestation. These early
term births were also associated with increased death during infancy,
compared to those occurring at 39 to 41 weeks ("full term) term, but no
adverse effects in the health of the mothers or babies.
Problems among babies delivered "pre-term" in this study included
respiratory distress, jaundice and low blood sugar. The American College
of Obstetricians and Gynecologists and medical policy makers review
research studies and find increased incidence of suspected or proven
sepsis, RDS, Hypoglycemia, need for respiratory support, need for NICU
admission, and need for hospitalization > 4 5 days.
Other risks include wet lung: Retention of fluid in the lungs can
occur if not expelled by the pressure of contractions during labor.
Potential for early delivery and complications: Preterm delivery is possible
if due-date calculation is inaccurate. One study found an increased risk
of complications if a repeat elective Caesarean section is performed even
a few days before the recommended 39 weeks. Higher infant mortality
risk: In C-sections performed with no indicated risk (singleton at full
term in a head-down position), the risk of death in the first 28 days of life
has been cited as 1.77 per 1,000 live births among women who had Csections, compared to 0.62 per 1,000 for women who delivered vaginally

Patient-centered objectives:
1. The patient will be relieved from her present discomfort.
2. The patient will show interest and will cooperate on her treatment
for fast recovery.
3. The patient will manifest a sense of well-being.
4. The patient will be able to share emotions, feelings and out-look
about her present condition.
5. The patient and the patients family will be aware on the risk
factors brought my cesarean section.

CHAPTER II
PATIENTS PROFILE

A) Biography
Patient JLJ is a 23 year old Filipina born on July 16, 1980 at
Pozorrubio

Community

Hospital.

She

is

currently

residing

at

Pozorrubio, Pangasinan with her husband and son together with her
parents. She is affiliated with Iglesia ni Cristo. She is a college
undergraduate and is fluent in tagalog, ilocano and english.

B) Reasons for Seeking Health Care

Patient JLJ was on her 37th week of pregnancy and was
admitted prior to the delivery of her twins through a caesarian
section. Early in the morning, she started to urinate more frequent
than the usual. There was also the presence of the mucus plug. At
5:00 pm of January 17, 2014, patient JLJ started feeling pain on her
back that radiates to her lower abdomen.

C) History of Present Health Concern

Patient JLJ was on her 11th week of gestation when she found
out about her pregnancy through a pregnancy test kit. She had her
regular check-ups at their barangay health center. Morning of

December 8, 2013, she started having her false labor characterized

as having irregular contractions that stops when she walks or
changes position and experiencing pain on her abdomen that
radiates to her groin area. During the afternoon of the same day, she
went to Estradas Medical Clinic to have her check up. She had
undergone her first ultrasound and had been reported later on that
she has a multiple pregnancy of two male fetuses.
On January 17, 2014 at 10:00 pm, patient JLJ was admitted to
ITRMC. She had normal contractions, 100% cervical effacement and
a cervical dilatation of 7 cm. At 10:35 pm, 8 cm cervical dilatation
and sudden gush of a clear amniotic fluid occurred. Patient JLJ
G2P2 delivered her first baby boy that was on a cephalic presentation
at 11:07 pm with a weight of 2.85 kg and her second baby boy that
was on a frank-breech presentation at 11:10 pm with a weight of 2.6
kg through a caesarean section.

D) Past Health History

Patient

JLJ

was

fully

immunized

and

has

complete

immunization of tetanus toxoid vaccines. She experienced simple

cough and colds during her pregnancy and used calamasi juice as a
remedy. She had an accident of slipping during her first trimester
but did not affect the babies, however, she had her left foot sprained.

E) Family Health history

The patient also expressed that she is not the only one in the
family that had been through a multiple pregnancy. She had a twin
brothers that had, although, died during pregnancy. Her female
cousin also had a multiple pregnancy of a full term live sets of twins.

F) Lifestyle and Health Practices

i. Description of a typical day
Patient JLJ usually wakes up at 6:00 am and eats her
breakfast at 7:00 am. She describes her typical day by doing house
errands, watching television, talking to her babies, teaching her 4
year old eldest son and resting on free hours.

ii. Nutrition and Waste Management

Her diet is mainly composed of rice, fish, meats, vegetables
and fruits. She eats at least three times a day with a morning and
afternoon snack. Her breakfast usually consists of milk, two cups
of rice and fried courses. At lunchtime, she takes at least one and
a half cup of rice and usually a viand of vegetables and fish or
meat. As for her snack, she usually eats bread and drinks soft
drinks. She sometimes takes juices and seldom eats junk foods.
Her dinner is mainly composed of one cup of rice and fish. She

usually eats banana after meal and also apples, pears and oranges
during daytime.

iii. Activity Level and Exercise

Patient JLJs daily activity and exercise includes her walking
during morning or afternoon and performing household chores
such as cooking, washing the dishes and cleaning the house.

iv. Sleep and Rest

Patient JLJ usually sleeps for 7-8 hours a day. She usually
sleeps around 10-11 pm and always wakes up at 6 am. She
sometimes takes her nap in the afternoon when she gets tired or
has nothing to do.

v. Medications and Substance Used

The patient never smoked cigarette. She seldom drinks
alcohol but never had alcohol intake during her pregnancy. Patient
JLJ had taken ferrous fumarate and folic acid during pregnancy.

vi. Education and Work

Patient JLJ is a college undergraduate. She is a housewife.
Her husband works as an electrician at her relatives electrician
shop. They have a monthly income of at least Php 5,000.

vii.

Social Activities
The patient usually socialize with her neighbors by spending

some of her free tome talking and sharing stories with them. She
also attends celebrations such as birthdays or weddings when she
is invited.

viii. Values and Belief System

She strongly believes in their doctrine. She does not believe
in hilots, albularyos or quack doctors.

ix. Stress Level

Patient JLJ expresses her problems or difficulties with her
husband. He husband provides her strength and guides her all the
way until she feels better. She also shares problems with her
parents such as financial problems.

x. The Environmental Living Situation

Their house is made up of concrete and is located in a
barrio. They get their water supply for bathing and washing dishes
and clothes from Pozorrubio Water District (POWAD) and from a
deep well. They have electricity supply. Their environment is
composed of trees and other plants, children playing on the street
and some bicycles and tricycles.

CHAPTER III
PHYSICAL ASSESSMENT

The physical assessment was conducted on January 20, 2014 at

6:00 pm from head to toe/cephalocaudal through inspection, palpation,
percussion and auscultation.

A. General Appearance
A female patient that is conscious and conversant. The patient
has a normal body built with no abnormal appearance but has a little
difficulty in moving. The assessed vital signs are as follows: BP =
110/80 mmhg, temperature = 36.5C, RR = 20 bpm, PR = 82 bpm.

B. Integumentary
The skin color is fair and has no presence of jaundice. It is
warm to touch, dry, has no pallor and has no edema. The fingernails
have a good capillary refill that lasts for less than 2 seconds. The
fingernails are complete and pinkish in color.

C. Head and face

The patients head is normocephalic. Her hair color is black, it
is also dry and equally distributed. The forehead is normal in size and

shape. Eyebrows are evenly distributed. Both pupils constrict when

directed to light and are brown, round and symmetrical. The upper
and lower conjunctiva was pink with white sclera. Upper connection
of the ear is parallel with the outer canthus of the eye. Lips has no
fissures and tongue is located in the midline. Gums are pink. The
teeth are complete.

D. Neck
The neck has no tenderness during palpation and no visible
mass.

E. Chest/Thorax/Lungs
Symmetrical chest expansion, no retractions, RR =20 bpm.

F. Heart
No abnormal heart sounds during auscultation.

G. Abdomen
Distended abdomen. Has a vertical cesarean section suture.
linea nigra and striae gravidarum were visible. Has no abnormal
bowel sounds.

H. Upper and lower extremities

Patient has no IVF. Patient can flex, entend, abduct, adduct,
rotate and depress her upper and lower extremeties.

I. Genital and urethra

The client has no vaginal bleeding and has no IFC.

CHAPTER V
ANATOMY AND PHYSIOLOGY

The female reproductive system includes the ovaries, fallopian

tubes, uterus, vagina, vulva, mammary glands and breasts. These
organs are involved in the production and transportation of gametes
and the production of sex hormones. The female reproductive system
also facilitates the fertilization of ova by sperm and supports the
development of offspring during pregnancy and infancy.

Vulva
The vulva is the collective name for the external female genitalia
located in the pubic region of the body. The vulva surrounds the external
ends of the urethral opening and the vagina and includes the mons
pubis, labia majora, labia minora, and clitoris. The mons pubis, or pubic
mound, is a raised layer of adipose tissue between the skin and the
pubic bone that provides cushioning to the vulva. The inferior portion of
the mons pubis splits into left and right halves called the labia majora.
The mons pubis and labia majora are covered with pubic hairs. Inside of
the labia majora are smaller, hairless folds of skin called the labia
minora that surround the vaginal and urethral openings. On the superior
end of the labia minora is a small mass of erectile tissue known as
the clitoris that contains many nerve endings for sensing sexual
pleasure.

Breasts and Mammary Glands

The breasts are specialized organs of the female body that contain
mammary glands, milk ducts, and adipose tissue. The two breasts are
located on the left and right sides of the thoracic region of the body. In
the center of each breast is a highly pigmented nipple that releases milk
when stimulated. The areola, a thickened, highly pigmented band of skin
that surrounds the nipple, protects the underlying tissues during
breastfeeding. The mammary glands are a special type of sudoriferous
glands that have been modified to produce milk to feed infants. Within
each breast, 15 to 20 clusters of mammary glands become active during
pregnancy and remain active until milk is no longer needed. The milk
passes through milk ducts on its way to the nipple, where it exits the
body.

Ovaries
The ovaries are a pair of small glands about the size and shape of
almonds, located on the left and right sides of the pelvic body cavity
lateral to the superior portion of the uterus. Ovaries produce female sex
hormones such as estrogen and progesterone as well as ova (commonly
called "eggs"), the female gametes. Ova are produced from oocyte cells
that slowly develop throughout a womans early life and reach maturity
after puberty. Each month during ovulation, a mature ovum is released.
The ovum travels from the ovary to the fallopian tube, where it may be
fertilized before reaching the uterus.

Fallopian Tubes
The fallopian tubes are a pair of muscular tubes that extend from
the left and right superior corners of the uterus to the edge of the
ovaries. The fallopian tubes end in a funnel-shaped structure called the
infundibulum, which is covered with small finger-like projections called
fimbriae. The fimbriae swipe over the outside of the ovaries to pick up
released ova and carry them into the infundibulum for transport to the
uterus.

Uterus
The uterus is a hollow, muscular, pear-shaped organ located
posterior and superior to the urinary bladder. Connected to the two

fallopian tubes on its superior end and to the vagina (via the cervix) on
its inferior end, the uterus is also known as the womb, as it surrounds
and supports the developing fetus during pregnancy. The inner lining of
the uterus, known as the endometrium, provides support to the embryo
during early development. The visceral muscles of the uterus contract
during childbirth to push the fetus through the birth canal.

Vagina
The vagina is an elastic, muscular tube that connects the cervix of
the uterus to the exterior of the body. It is located inferior to the uterus
and posterior to the urinary bladder. The vagina functions as the
receptacle for the penis during sexual intercourse and carries sperm to
the uterus and fallopian tubes. It also serves as the birth canal by
stretching to allow delivery of the fetus during childbirth. During
menstruation, the menstrual flow exits the body via the vagina.

Female Reproductive System Physiology

The Reproductive Cycle

The female reproductive cycle is the process of producing an ovum
and readying the uterus to receive a fertilized ovum to begin pregnancy.
If an ovum is produced but not fertilized and implanted in the uterine
wall, the reproductive cycle resets itself through menstruation. The entire
reproductive cycle takes about 28 days on average, but may be as short
as 24 days or as long as 36 days for some women.

Oogenesis and Ovulation

Under the influence of follicle stimulating hormone (FSH), and
luteinizing hormone (LH), the ovaries produce a mature ovum in a
process known as ovulation. By about 14 days into the reproductive
cycle, an oocyte reaches maturity and is released as an ovum. Although
the ovaries begin to mature many oocytes each month, usually only one
ovum per cycle is released.

Fertilization
Once the mature ovum is released from the ovary, the fimbriae
catch the egg and direct it down the fallopian tube to the uterus. It takes
about a week for the ovum to travel to the uterus. If sperm are able to
reach and penetrate the ovum, the ovum becomes a fertilized zygote

containing a full complement of DNA. After a two-week period of rapid

cell division known as the germinal period of development, the zygote
forms an embryo. The embryo will then implant itself into the uterine
wall and develop there during pregnancy.

Menstruation
While the ovum matures and travels through the fallopian tube,
the endometrium grows and develops in preparation for the embryo. If
the ovum is not fertilized in time or if it fails to implant into the
endometrium, the arteries of the uterus constrict to cut off blood flow to
the endometrium. The lack of blood flow causes cell death in the
endometrium and the eventual shedding of tissue in a process known as
menstruation. In a normal menstrual cycle, this shedding begins around
day 28 and continues into the first few days of the new reproductive
cycle.

Pregnancy
If the ovum is fertilized by a sperm cell, the fertilized embryo will
implant itself into the endometrium and begin to form an amniotic cavity,
umbilical cord, and placenta. For the first 8 weeks, the embryo will
develop almost all of the tissues and organs present in the adult before
entering the fetal period of development during weeks 9 through 38.

During the fetal period, the fetus grows larger and more complex until it
is ready to be born.

Lactation
Lactation is the production and release of milk to feed an infant.
The production of milk begins prior to birth under the control of the
hormone prolactin. Prolactin is produced in response to the suckling of
an infant on the nipple, so milk is produced as long as active
breastfeeding occurs. As soon as an infant is weaned, prolactin and milk
production end soon after. The release of milk by the nipples is known as
the milk-letdown reflex and is controlled by the hormone oxytocin.
Oxytocin is also produced in response to infant suckling so that milk is
only released when an infant is actively feeding.

CHAPTER V
LABORATORY AND DIAGNOSIS PROCEDURE

HEMATOLOGY RESULT

Parameter

Result

Unit

WBC

15.99

Neu%

67.7

50.0 70.0

Lym%

26.8

20.0 40.0

Mon%

2.3

3.0 12.0

Eos%

3.0

0.5 - 5.0

Bas%

0.2

0.0 1.0

RBC

4.20

HGB

111

g/L

110 150

HCT

34.5

37.0 47.0

MCV

82.1

fL

80.0 100.0

MCH

26.4

pg

27.0 34.0

MCHC

322

g/L

320 360

RDW-CV

14.1

11.0 16.0

RDW-SD

48.7

fL

35.0 56.0

PLT

433

x10^9/L

x10^12/L

x10^9/L

Ref. Range

4.0 10. 00

3.50 5.00

150 450

MPV

7.3

fL

6.5 12.0

PCT

0.316

0.108 0.282

Blood type O
Bleeding Time: (1 3 minutes)
Clotting Time:

(2 4 minutes)

INTERPRETATION:
Hematology result shows that the elevated WBC, clients first line
of defense, responded to the process undergone by the client.

ULTRASOUND REPORT

GENERAL PRESENTATION(Twin):

A Breech

AMNIOTIC FLUID VOLUME:

Normal

PLACENTA LOCATION:

Posterior

PREVIA:

No Previa

B - Vertex

MEASUREMENTS: (Twin)
A

CRL
BPO

cm
7.8

8.2

cm

HC

28.3

29

cm

AC

26.8

27

cm

FL

5.7

cm

OFD

cm

A
Best Estimated U/S Gest. Ages:
Expected Date of Delivery:
Estimated Fetal Weight

(TWIN)

31

2014/02/04
1673

B
31 weeks

5 days

2014/02/04
1735 gms

FINAL IMPRESSION:
Multiple Pregnancy Uterine 31 31 weeks 0 5 days AOG by Fetal
Biometry Breech Cephalic Presentation, live, singleton, male male
fetuses
Estimated Fetal Weight (1673 1735 gms.)
Good Cardiac Activity (Fetal Heart Rate 145

138 BPM)

Amniotic Fluid Adequate

Placenta Posterior

Grade 2

Previa no

Expected date of confinement: 2014/02/04

2014/02/04

INTERPRETATION:
Multiple Fetal Pregnancy Breech- Cephalic Presentation
Diamniotic Dichronic Type of Twinning
Placenta Posterior Grade 2, no Previa
Twin

FHB

145 BPM

male fetus

Twin

FHB

138 BPM

male fetus

EDD = 2014/02/04 Twin A

2014/02/04 Twin B

CHAPTER IX
EVALUATION

Patient JLJ was admitted to ITRMC on January 17, 2014 to deliver

her twins through cesarean section due to malpresentation. Patient JLJ
had felt the normal labor signs prior to her admission.
Nursing quality care was provided to reduce the patients anxiety
and discomfort due to the done procedure. The patient was able to move
and perform some activities by assisting her. However, the patient
vocalized that she needs time to regain her energy so that she could start
doing her activities independently. Thus, the objective of relieving her
from her present condition was partially met.
The patient was able to communicate and participate when health
care was being rendered. The patient showed interest on the imparted
health teachings about breast feeding, proper hygiene and safety
measures for her well-being as well as her twins. The patient was able to
receive an effective nursing intervention in meeting her needs and her
concern. A clean and reliable environment has been provided to promote
comfort and to lessen down her stress. The family has also been
encouraged to show support to the patient by providing emotional
support and by rendering care. Thus, the objectives were met.