Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

Tamag, Vigan City
2700 Ilocos Sur
COLLEGE OF HEALTH SCIENCES

A Midwife Case Study on

ECTOPIC PREGNANCY

By
Jan Audrey Galinato
BS Midwifery
 TABLE OF CONTENTS

I. Introduction
II. Objectives
III. Patient’s Profile
IV. History of past and present illness
V. Physical assessment
VI. Anatomy and physiology of the organ involved
VII. Pathophysiology
VIII. Laboratory exams/diagnostic procedure
IX. Care plan
X. Drug study
XI. Discharge Planning
XII. Evaluation
XIII. References
I. INTRODUCTION

Pregnancy is considered by many as not less than a miracle. Midwifery is a

special branch of medical profession which is mainly dominated by women. It is a

profession that mainly deals with pregnancy and childbirth. In general, the roles of

midwife are to look into pregnancy or childbirth, and of course the antenatal care

during the pregnancy. A midwife is expected to look into aspects such as medical

examinations, palpation, listening to the baby's heart and checking the well-being of

both mother and baby, in preparation for the birth.

An ectopic pregnancy occurs when the baby starts to develop outside the

womb (uterus). The most common site for an ectopic pregnancy is within one of the

tubes through which the egg passes from the ovary to the uterus (fallopian tube).

However, in rare cases, ectopic pregnancies can occur in the ovary, stomach area, or

cervix. In the developed world, Ectopic pregnancy occurs in about 1 in 250

pregnancies amounting to approximately 70,000 cases annually, 5,833 per month,

1,346 per week, 191 per day, 7 per hour. In the Philippines, unpublished reports have

estimated the incidence to be just about 22, 194 each year.

An ectopic pregnancy is commonly referred to as tubal pregnancy because 95

percent occur in a fallopian tube. An ectopic pregnancy needs to be treated

immediately to avoid fallopian tube damage or life threatening blood loss. When

identified early, ectopic pregnancies are treatable with medication that stops the

pregnancy., if the pregnancy is further along, laparoscopy is usually performed to

remove the ectopic tissue and repair the fallopian tube. Currently, laparotomy is the

preferred technique when the patient is hemodynamically unstable, the surgeon has
not been trained in laparoscopy, physical facilities and supplies to perform

laparoscopic surgery are lacking or technical barriers to laparoscopy are present.

If the ectopic pregnancy has ruptured or bleeding persists, salpingcetomy is a

very common option. This procedure involves excision of segment of the Fallopian

tube involved in the ectopic pregnancy. The tubal segment to be removed is

coagulated and cut off with bipolar forceps.

This case study will provide information that may help the readers/listeners

understand the cause of condition. This case study will enhance the knowledge and

skills in dealing with patient who suffers from this condition. Further complications

will be prevented if immediate proper action is provided and intervention is rendered.

Therefore it is important that the health care provider develop skills in proper

management of the client having this condition.

II. OBJECTIVES

General objectives:

After through research and analysis, the student midwife will be able to

present important information about Ectopic Pregnancy in relation to the client’s

condition, enhance knowledge and skills in dealing with the client having this kind of

condition and apply this knowledge and skills appropriately in the clinical setting.

Specific Objectives:

• To discuss the client’s personal data, family profile, past health history, current

health history, and physical assessment using cephalocaudal assessment.

• To review the anatomy and physiology of the organ involved in the patient’s disease
• To correlate the results of the diagnostic procedures to its normal values.

• To discuss the drug study of ectopic pregnancy

• To develop an effective midwifery care plan in which the client may benefit.

• To formulate a discharge plan for the continuity of care.

III. PATIENT’S PROFILE

Name: Mary Ann Tabudlo

Case Number: 327255

Date of Birth: November 13, 1990

Place of Birth: Narvacan, Ilocos Sur

Address: Sulvec, Narvacan, Ilocos Sur

Age: 30 years old

Occupation: teacher

Status: Married

Religion: Roman Catholic

Date Admitted: August 29, 2021

Admitting Diagnosis: Ectopic Pregnancy G1P0

Post-op Diagnosis: Ruptured Tubal Pregnancy; Right Isthmic Area G1P0

IV. HISTORY OF PAST AND PRESENT ILLNESS

Mrs. I Mrs. J

Ms. A (sister)

Mr. D (husband)

Mrs. B

Baby

LEGEND:
Female Patient

Male Baby

A. Past Health History

According to the patient, her childhood illnesses were common cough, colds

and fever. She didn’t experienced any injuries or accidents. Her first hospitalization is

when she knows that she is pregnant, that’s the time she went to hospital. During her

first month of pregnancy, she had bleeding. She sought for medical help and was

asked to take a rest and avoid strenuous activities to avoid complication in her

pregnancy.
B. Present Health History

During the 3rd week of July, the patient experienced on and off vaginal

spotting. No other signs and symptoms related to ectopic pregnancy manifested

during this time. This condition persisted and on the 4 th week of august, the patient

noted hypogastric pain and described it like having dysmenorrhea. The severity of

pain increased, added with another vaginal spotting made her decide to eventually

seek for medical help. She first went to Narvacan Emergency Hospital and was then

referred to Northside District Hospital when she finally diagnosed with ectopic

pregnancy. A stat EXLAP was the ordered and after it was a Salpingectomy.

V. PHYSICAL ASSESSMENT
General Survey : Patient is a 30 years old female, stands 5’4, with pulse rate of 85
beats per minute, respiratory rate of 19 breathe per minute and a temperature of 36.2
C. The patient is conscious and coherent but weak. During the interview and physical
examination the patient had an eye to eye contact and she was cooperative.
REVIEW OF TECHNIQU NORMAL RESULT SIGNIFICANT
SYSTEMS E USED
(IPPA)
Skin Inspection/ When skin is The patient’s Normal
pinched it skin is dry with
Palpation Pigmentation of the skin
goes to good skin
during
previous state turgor. Skin
immediately color is brown pregnancy is due to
(2 seconds). which is hormonal changes.
uniform in all
With fair
areas except for
complexion.
areas that are not
With dry skin
usually exposed
to sun such as
the axillae, the
legs and soles of
the feet. Skin is
warm to touch,
which is
uniform on both
extremities. A
 surgical wound
covered by a
sterile dressing
is noted on the
hypogastric area
of the patient’s
abdomen. Both
the right and left
hands have
scratches as it
served as IV
insertion sites.
Head Inspection The head is The head is
circumference circumference
without any without any
bumps and bumps and
inflammation inflammation
Skull Inspection/ Rounded, The patient’s
head is
Palpation normocephalic
normocephalic
and
and proportional
symmetrical,
to body size.
smooth and
Presences of
has uniform
nodules or
consistency. masses are not
Absence of noted.
nodules or
masses.
Face Inspection Symmetrical Facial features
facial and movements
movement, are symmetrical.
palpebral The patient is
fissures equal able to raise her
in size, eyebrows, close
symmetric her eyes, frown,
nasolabial and smile. Her
folds. face manifests a
feeling of slight
tiredness.
Hair Inspection Evenly The hair is
distributed evenly
hair. distributed over
scalp. It is oily
With short,
 black and and black in
shiny hair. color. Dandruffs
are present. Fine
With presence
hairs are evenly
of
distributed on
pediculosis both extremities.
Capitis

Nails Inspection Smooth and The tissues

surrounding the
has intact
nails of the
epidermis with
patient are
short and
intact. And
clean
when blanched
fingernails and
test performed,
toenails. color of the nail
of the client
Convex and returns into pink
with in less than 4
good capillary second.
refill time of 2
seconds.

Eyes and Vision

Eyebrows Inspection Hair evenly The hair in the
distributed patient’s
with skin eyebrows is
intact. evenly
distributed; skin
Eyebrows are
is intact and
symmetrically symmetrically
aligned and aligned with
have equal equal movement
movement. and there was no
noted. Her pupil
size in both eyes
are equal
Eyelashes Inspection Equally Equally
distributed and distributed and
curled slightly curled slightly
outward outward
Eyelids Inspection Skin intact Her eyelids
with no close
discharges and symmetrically;
no discharges and
discoloration. discolorations
were not noted.
Lids close
symmetrically
and blinks
involuntary.
Eyes Inspection The patient’s Her pupil size in
eyebrows have both eyes are
evenly equal, with a
distributed diameter of
hair, has intact 3mm when
skin, dilated and 2mm
symmetrically when
aligned, and constricted; with
has equal brisk reaction to
movement. light
The accommodation
conjunctiva is . According to
transparent, her, when
capillaries looking straight
sometimes ahead, she can
evident, and see objects in
sclera appears periphery. There
white and was no edema or
clear. tenderness noted
over her
lacrimal glands.
The cornea is The cornea is
transparent, transparent,
shiny and shiny and
smooth, smooth, details
details of iris of iris are
are visible. visible. The iris
The iris is is brown, flat
brown, flat and round. The
and round. patient’s visual
The patient’s acuity is normal
visual acuity is
normal
Ears Inspection The external Auricles are
 ear canal is smooth,
dry, has symmetrical and
presence of no discoloration
hair follicles, noted. Her
no pus or external pinna is
blood. Normal normoset;
voice tones are deformities,
audible the lesions or
patient. Sound inflammations
is heard on were not
both or present. Pinna
localized at recoils after it is
the center of being folded; it
the head. Ear is firm and non
is without tender. The ears
masses were physically
symmetrical in
size and
normoset since
both are located
in line with the
outer canthus of
hus eyes.
Normal voice
tones are
audible. She was
able to repeat
whispered words
and was able to
hear ticking
sound from the
watch in both
ears.

Nose and Inspection No tenderness The external

Sinuses on sinuses. nose is
The nose is in symmetrical,
the midline, straight and
has no uniform in color.
discharges, no Nasal flaring
nasal flaring, was not noted.
both nares are Color is the
patent and no same with the
bone and entire face; there
cartilage was no
 deviation tenderness noted
noted on upon palpation.
palpation. Lessions and
tenderness were
both absent.
Nassal mucosa
was pinkish.
Both left and
right nares were
patent, with no
discharges; air
could freely
move in and out
when the patient
breathes. The
nasal septum is
intact and in the
midline without
deviations. The
frontal and
maxillary
sinuses were
non-tender upon
palpation. Sense
of smell was
good. Patient
was able to
differentiate
water from that
of alcohol,
through scent.

Mouth Inspection The buccal The patient’s

mucosa is buccal mucosa
uniformly pink is uniformly
in color, pink in color,
moist, smooth, moist, smooth,
soft, glistening soft, glistening
and elastic in and elastic in
texture and texture and has
has no lesions. no lesions. teeth
teeth are white are white to
to yellowish in yellowish in
color, gums color, gums are
are pink, pink, moist,
 moist, firm, firm, has no
has no retraction and
retraction and bleeding of
bleeding of gums.
gums.
Tongue is Tongue is pink,
pink, has thin has thin whitish
whitish color color. Ovula is
positioned in the
Ovula is
midline of soft
positioned in
palate. The
the midline of
tonsils are pink
soft palate.
in color and
The tonsils are
have no
pink in color
discharges.
and have no
discharges.
Throat and Inspection The neck The neck
Neck muscles are muscles are
equal in size. equal in size.
The client The client
showed showed
coordinated, coordinated,
smooth head smooth head
movement movement with
with no no discomfort.
discomfort.
The lymph
The lymph nodes of the
nodes of the client are not
client are not palpable.
palpable.
The trachea is
The trachea is placed in the
placed in the midline of the
midline of the neck.
neck.

Respiratory Auscultation With normal The respiratory

breath sounds rate is 20 beats
without per minute
Dyspnea
The breathing
 sound is normal
Cardiovascular Palpation/ With audible The heart beats
sounds of 23 is normal
Auscultation
bowel
sounds/
minute. (thin
clients, you
will see visible
peristalsis)
The heart rate is
78 beat per
minute
Breast and Inspection Symmetrical Enlargement of Normal
Axilla at rest, Areola breast without
Enlargement of the
is round and inflammation
breast during
normal, no and bumps. Both
wounds or areola are dark pregnancy is due to
sores, no brown in color hormonal
orange peel or and both nipples
edema, non are visible. changes.

fixated- moves
freely no
retractions or
dimpling. No
lumps or
palpable
masses and no
discharges on
nipples

Abdomen Percussion/ Symmetrical The patient’s Striae

abdomen has
palpate movements gravidarum (striae
same color with
cause by distensae, or
his chest. The
respirations.
hypogastric area stretch marks) are seen
No
is covered with in about
visible brace. Beneath it
is a surgical 90% of white
pulsation, not
distended wound as a pregnant women during
result of surgery. the last
Unblemished The umbilicus is
skin, uniform medially located trimester. They are less
 in color, and shows no common in Asians and
signs of
symmetric blacks, and show a
inflammation.
contour, not familial tendency. It
Bowel sounds
distended. No does not completely
are present upon
scar, and non
auscultation. disappear.
distended There were
symmetric
movements
between the
abdomen and
respiration

Urinary Inspection The urine The urine color

color is is normal
normal

Musculoskeleta Inspection The muscles The muscles has

l has no bumps no bumps and
and inflammation
inflammation

Neurological Inspection The patient The patient has a

has a presence presence of
of mind. She mind. She
response response
accurately accurately

Reproductive Inspection During The patient’s

pregnancy, the cervix is open
cervix is
closed at the
lower end
Vagina Inspection No mass, No mass,
tenderness or tenderness or
swelling, or swelling, or
bruising. bruising.
circumcision circumcision
scar otherwise scar otherwise
no scar no scar
 Pubic hair are Pubic hair are
normal normal

VI. ANATOMY AND PHYSIOLOGY

The vagina is a thin-walled tube 8 to 10 cm long. It lies between the bladder and

rectum and extends from the cervix to the body exterior. Often called the birth canal,

the vagina provides a passageway fro the delivery of an infant and for the menstrual

flow to leave the body.

The cervix (from Latin “neck”) is the lower, narrow portion of the uterus where it

joins with the top end of the vagina. Where they join together forms an almost 90

degree curve. It is cylindrical or conical in shape and protrudes through the upper

anterior vaginal wall. Approximately half its length is visible with appropriate

medical equipment; the remainder lies above the vagina beyond view. It is

occasionally called “cervix uteri”, or “neck of the uterus”.

During menstruation, the cervix stretches open slightly to allow the endometrium to

be shed. This stretching is believed to be part of the cramping pain that many women

experience. Evidence for this is given by the fact that some women’s cramps subside

or dissapear after their first vagina birth because the cervical opening has widened.

The portion projecting into the vagina is referred to as the portio vaginalis or

ectocervix. On average, the ectocervix is three cm long and two and a half cm wide. It

has a convex, elliptical surface and is divided into anterior and posterior lips. The

ectocervix’s opening is called the external os. The size and shape of the external os

and the ectocervix varies widely with age, hormonal site, and whether the woman has

had a vaginal birth, the ectocervix appears bulkier and the external os appear wider,

more slit-like and gaping.

The passageway between the external os and the uterine cavity is referred to as the

endocervical canal. It varies widely in length and width, along with cervix overall.

Flattened anterior to posterior, the endocervical canal measures seven to eight mm at

its widest in reproductive-aged women. The endocervical canal terminates at the

internal os which is the opening of the cervix inside the uterine cavity.

During childbirth, contractions of the uterus will dilate the cervix up to 10 cm in

diameter to allow the child to pass through. During orgasm, the cervix convulses and

the external os dilates.

The uterus is shaped like an upside-down pear, with a thick lining and muscular walls.

Located near the floor of the pelvic cavity, it is hallow to allow a blastocyte, or

fertilized egg, to implant and grow. It also allows for the inner lining of the uterus to

build up until a fertilized egg is implanted, or it is sloughed off during menses.’

The uterus contains some of the strongest muscles in the female body. These muscles

are able to expand and contract to accommodate a growing fetus and then help push

the baby out during labor. These muscles also contract rhythmically during an orgasm

in a wave like action. It is thought that this is to help push or guide the sperm up the

uterus to the fallopian tubes where fertilization may be possible.

The uterus is only about three inches wide, but during pregnancy it changes rapidly

and dramatically. The top rim of the uterus is called the fundus and is a landmark for

many doctors to track the progress of a pregnancy. The uterine cavity refers to the

fundus of the uterus and the body of the uterus.

Helping support the uterus to the pelvic wall and abdominal wall. During pregnancy

the ligaments prolapse due to the growing uterus, but retract after childbirth. In some

cases after menopause, they may lose elasticity and uterine prolapse may occur. Thus

can be fixed with surgery.

Some problems of the uterus include uterine fobroids, pelvic pain (including

endometriosis, adenomyosia), pelvic relaxation (or prolapse), heavy or abnormal

menstrual bleeding, and cancer. It is only after all alternative options have been

considered that surgery is recommended in theses cases. This surgery is called

hysterectomy. Hysterectomy is the removal of the uterus, and may include the

removal of one or both of the ovaries. Once performed it is irreversible. After a

hysterectomy, many women begin a form of alternate hormone therapy due to the lack

of ovaries and hormone production.

The fallopian tubes are paired, tubular, seromuscular organs whose course runs

immediately from the cornua of the uterus toward the ovary laterally. The tubes are

situated in the upper margins of the broad ligaments between the round and utero
ovarian ligaments. Each tube is about 10 cm long with variations in length from 7 to

14 cm. The abdominal ostium is situated at the base of a funnel-shaped expansion of

the tube, the infundibulum, the circumference of which is enhanced by irregular

processes called fimbriae. The ovarian fimbria is longer and more deeply grooved

than others and is closely applied to the tubal pole of the ovary. Passing medially, the

infundibulum opens into the thin-walled ampulla forming more than half the length of

the tube and 1 or 2 cm in outer diameter; it is succeeded by the isthmus, a round and

cord-like structure constituting the medial one-third of the tube and 0.5-1 cm in outer

diamter. The instertitial or conual portion of the tube continues from the isthmus

through the uterine wall to empty into the uteine cavity. This segment of the tube is

about 1 cm in length and 1 mm in inner diameter.

The tubal wall consists of three layers: the internal mucosa (endosalpinx), the

intermediate muscular layer (myosalpinx), and the outer serosa, which is continuous

with the peritoneum of the broad ligament and uterus, the upper margin of which is

the mesosalpinx. The endosalpinx is thrown into longitudinal folds, called primary

folds, increasing in number toward the fimbria and lined by columnar epithelium of

three types: cliated, secretory, and peg cells. In the ampullary and infundibular

sections, secondary folds of the tubal mucosa also exist, markedly increasing the

surface areas of these segments of the tube. The myosalpinx actually consists of an

inner circular and an outer longitudinal layer to which a third layer is added in the

interstitial portion of the tube.

Peristaltic contraction of the smooth muscle fibers in the tubal wall allows the

gametes (the sperm and egg) to be brought together, thus allowing fertlization and

subsequent transport of the fertilized ovum from the normal site of fertilization in the

ampulla to the normal site of implantation in the uterus.,

There are fewer ciliated cells in the isthmus than in the ampullary portion of the tube,

whereas they are most prominent in the fimbirated infundibukum. Ciliation and

deciliation is a continuous process throghout the menstrual cycle. Ciliation is

maximum in the periovulatory period, particularly in the fimbria. Estrogen enhances

the process o ciliation, whereas progesterone inhibits it, so significant deciliation

occurs in atrophic postmenopausal tube.

Ciliary activity is responsible for the pickup of ova by, the fimbrial ostium and

movement through the ampulla, as well as the distribution of the tubal fluid which

supports gamete maturation and fertilization and facilitates gamete and embryo

transport. The close approximation between the ovary and fimbria is likely to be

important for ovum pickup, although, transperitoneal migration has been reported.

The paired ovaries are pretty much the size and shape of almonds. An internal view of

an ovary reveals many tiny saclike structures called ovarian follicles. Ecah follicle

consists of an immature egg called an oocyte, surrounded by one or more layers of

every different cells called follicle cells.

The ovaries are for oogenesis - the production of eggs (female sex cells) and for

hormone production (estrogen and progesterone). as the developing egg begins to

ripen or mature, follicle enalarges and develops a fluid filled central region. When the

egg is matured, it is called a grafian follicle, and is ready to be rejected from the

ovary.

The process of ovulation is controlled by the hypothalamus of the brain and through

the relase of hormones secreted in the anterior lobe of the pituitary gland, (Luteinizing

hormone (LH) and follcile-stimulating Hormone (FSH). in the follicular (pre-

ovulatory) phase of the menstrual cycle, the ovarian follicle will undergo a series of
transformation called cumulkus expansio, this is stimulated by the secretion of FSH.

After this is done, a hole called the stigma will form in the follicle, and the ovum will

leave the follicle through this hole. Ovulation is triggered by a spike in the amount of

FSH and LH released from the pituitary gland. During the luteal (post-ovulatory)

phase, te ovum will travel the fallopian tubes toward the uterus. If fertilized by a

pserm, it may perform implantation there 6-12 days later.

In humans, the few days near ovulation constitute the fertile phase. The average time

of oculation is the fourteenth day of an average length (twenty-eight day) menstrual

cycle. It is normal for the day of ovulation to vary from the average, with ovulation

anywhere between the tenth and nineteenth day being common.

Cycle length alone is nit a rekiable indicator of the day of ovulation. While in general

an earlier ovulation will result in a shorter menstrual cycle, and vice versa, the luteal

(post-ovulatory) phase of menstrual cycle may vary by up to a week between women.

Fertilization occurs when a single sperm cell has penetrated the oocyte. After sperm

entry, changes occur in the fertilized egg to prevent other sperm from gaining entry.

In fertilization, the genetic material of a sperm combines with the ovum to form a

zygote. After fertilization, the zygotes travels to the uterus through peristalsis and

cilia. The zygote generally gets implanted at the top of the uterus, beginning between

5 and 8 days after fertilization. This process is completed by 9 or 10 days. At this

time, the outer layer of this cell mass or thropoblast attaches itself by secreting the

required enzymes, which actually erode the uterine wall cells.

Ectopic pregnancy result from a delay in the passage of the fertilized ovum through

fallopian tube. This delay can result from anatomical abormalities of the tubes, such
as constriction and false passage formation (e.g. diverticulum), or from tubal

dysfunction as altered contractility or abnormal ciliary activity

VII. PATHOPHYSIOLOGY

Fertilized Egg

Etiology
-age
-sex

Blastocyst burrows into the

epithelium of the tubal wall

Trapping of blood vessels by

the same process as normal
implantation
Implantation on the tubal
mucosa

Errosive action of villous trophoblast

causes penetration of the tubal wall
which may extent to the peritoneal coat

Invasion of blood vessels causes

bleeding into the lumen, tubal wall or
peritoneal cavity

Sudden abdominal pain Abdominal ultrasound findings

-No intrauterine gestational sac
-HCG>650mlU/mL

Treatment/Management
 Salphingostomy
 Methotrexate
 Broad spectrum antibiotics
 Spontaneous regression (embryo Treatment/Management:
dies early in gestation)
 Salphingostomy
 Isthmic =6-8 weeks  Broad spectrum
 Interstitial= 14 weeks antibiotics
 Methotrexate
 Salphingcetomy if
there is blood in the
Bleeding shock peritoneum upon
culdocentesis

Uninterrupted invasion of
trophoblastic tissue or tearing of
extremely stretched tissue

Products of conception Treatment/Management:

completely/incompletely expelled into the
abdominal cavity or in between the folds  Salphingectomy to
of broad ligaments remove affected tube
and control bleeding
 Salphingoophorecto
my (removal of tube
with adjacent ovary)
Sharp Rupture/Tubal Rupture  Management of
abdominal pain shock
radiating to
 Methotrexate
shoulders and
neck  Constant hCG
monitoring
Placenta continues to grow  Micro-surgucal
following attachment to some repair of tube
abdominal structure

Abdominal implantation 2
degrees to tubal rupture
 Abdominal Ectopic Treatment/Management:
Hemorrhage
Pregnancy  Abdominal Surgery
 Removal of
fetus/placenta
 Constant hCG
monitoring
 Methotrexate

VIII. LABORATORY EXAMS/DIAGNOSTIC PROCEDURE

Order Rationale Remarks
Complete Blood CBC with PC determines the quantity of each Done
Count/Platelet Count quantity of blood cell in a given specimen of
blood, often including the amount of
hemoglobin, hematocrit, and the proportion of
various white blood cells. This is done to know
any condition of the client that may be
complicated by surgery
BT now BT determines patient’s blood type in caseof a Done
blood transfusion
PT PT determines the time it takes for blood to Done
clot
Schedule for STAT EXLAP To prepare for the upcoming surgery
Done

IX. DIAGNOSTICS EXAMS

Urinalysis
 Urinalysis is performed to screen for urinary tract disorders, kidney disorders, urinary
neoplasm and other medical conditions that produce changes in the urine. This test is
also used to monitor the effects of treatment of known renal or urinary condition.
Laboratory Test Normal Result Clinical Midwife
Value/ significance intervention
Results
Color Yellow, Yellow Colorless: Over- Pretest:
straw, amber (normal) hydration, diuretic
>provide patient with
therpy, diabetes
urine container with
insipidus and
lid.
melitus
>Instruct the patient
Dark red or pink:
to collect a sample of
porphyria,
urine, preferably on
hematuria, ingestion
arising in the
of red food coloring,
morning; must not be
beets, berries, fava
contaminated by
beans, rhubarb
toilet paper, toilet
Dark yellow: bile water, feces or
secretions.
Green:
pseudomonas >Women should not
bacteriuria, urinary collect urine during
bile pigments menstruation.
Appearance Clear to Cloudy Cloudy, smoky or >instruct patient to
faintly hazy (normal) hazy: pyuria, collect a midstream
bacteriuria, voided specimen
phosphates in urine
Reaction 4.0-8.0 6.0 (normal) If >8.0, finding may
Posttest:
be the result of UTI
if<4.0 may indicate >The lid must be
respiratory or sealed completely and
metabolic acidosis the container must be
labeled properly.
Specific gravity 1.003-1.030 1.030 Increased
(normal) in:dehydration, >Specimen must be
fever, profuse delivered to the
sweating, vomiting, laboratory
diarrhea, glycosuria, immediately
proteinuria, CHF,
adrenal
insufficiency,
SIADH
Decreased in:
 overhydration,
dieresis,
hypotension,
pyelonephritis,
glomerulonephritis,
renal tubular
dysfunction, severe
renal damage,
diabetes insipidus.
Albumin Negative Negative Positive in:
hyperglycemia,
diabetes mellitus
Epithelial cells- +++
Squamous
Pus cells ≤4 cells/HPF 5-8 Positive in: urinary
tract infection (UTI)

≥
Red blood cells ≤2 rbc hpf 0-2 hpf Positive in indicates
bleeding at some
location in the
urinary tract, from
the glomeruli to
urethra, or leakage
of rbc through the
glomerular
membrane.
Mucous threads ++

Complete Blood Count

The CBC is a series of different tests used to evaluate the blood and the cellular
components of RBC’s, WBC’s and platelets. The CBC is used to assess the patient for
anemia, infection, inflammation, polycythemia, hemolytic, and the effects of ABO
incompatibility, leukemia and dehydration status.
Laboratory Test Normal Result Clinical Midwife
Value/ significance intervention
Results
Hemoglobin 115-175 g/L 86 g/dL Increased in: Pretest:
polycythemia,
(low) >Identify patient and
dehydration, acute
check the requisition
thermal injury,
 COPD form with the
patient’s
Decreased in:
identification
hemorrhage,
bracelet.
bleeding, anemia,
cirrhosis, leukemia, >Inform the patient
lymphoma that blood needs to be
drawn from the
Leukocytes 5.0- 12.16 Increased in:
designated site.
10.0x10^3/uL infection,
(high) Provide reassurance
inflammation,
to help limit anxiety
leukemia,
lymphoma, mumps, >The patient may be
cancer (liver, seated or in supine
intestine), tissue position. The
necrosis (burns, patient;s arm is in
gangrene, extension, with easy
myocardial access to the
infarction), antecubital fosa.
varicella, rubeola,
Posttest:
leukemoid reaction
>Instruct patient to
Decreased in:
continue compression
aplastic anemia,
of the puncture site
bone marrow
for 2 to 5 minutes or
deprssion,
until the bleeding
pernicious anemia,
stops.
some infectious or
parasitic diseases, >Assess the patient’s
brucellosis, typhoid arm to ensure that the
fever, viral bleeding has ceased.
infections Apply adhesive
(influenza, rubella, bandage as needed.
hepatitis), typhus,
>If hematoma occurs
dengue fever,
or if there is still
antineoplastic drugs,
bleeding, ask the
toxic injestion of
patient to continue
heavy metals, SLE,
compression of the
felty syndrome
site or elevate the arm
Neutrophils 55-75 73 Increased in: and rest in on top of
chronic the head.
(normal)
myelogenous
leukemia (CML),
bacterial infection,
severe burns,
rheumatic fever,
ketoacidosis, cancer,
 down syndrome
Decreased in: drug
reaction,
autoimmune
neutropenia,
maternal antibody
production, aplastic
anemia, radiation or
chemotherapy,
megaloblastic
anemia,
hypersplenism
Lymphocytes 20-35 17 (low) Increased in:
infectious
mononucleoisis,
infectious hepatitis,
cytomegalovirus
infection, pertussis,
brucellosis,
tuberculosis,
syphilis,
lymphocytic
leukemia
Decreased in:
thoracic duct
drainage, right-sided
heart failure,
Hodgkin;;s disease,
SLE, aplastic
anemia, HIV
infection, military
TB, renal failure,
Terminal cancer
Monocytes 2-10 6 (normal) Increased in: acute
infection,
tuberculosis,
syphilis, brucellosis,
sarcoidosis,
ulcerative colitis,
CML,
myeloprofilerative
disease (MPD),
hodgkin’s disease,
malignancy,
 rheumatoid arthritis,
sarcoidosis, allergic
reaction to drugs,
allergies
Decreased in:
pyrogenic infection,
shock, postsurgical
response
Basophils 0-1 0 normal Increased in:
hypersensitivity
reactions, ulcerative
colitis, chronic
hemolytic anemia,
Hodgkin’s disease,
myxedema, CML,
polycythemia
Decreased in:
hyperthyroidism,
pregnancy, stress,
cushing syndrome
Hematocrit 0.36-0.52 0.26 (low) Increased in:
plycythemia,
dehydration,
Addison’s disease,
acute thermal injury,
extreme physical
exertion, COPD
Decreased in:
hemorrhage,
anemia, hemolytic
anemia, fluid
overload, fluid
retention, cirrhosis,
leukemia,
lymphoma

Diagnostic Exam Normal Result Clinical Midwife

Results significance intervention

Transvaginal scan No amniotic Findings: Abnormal in: cyst, Pretest:

or functional tumor,
*uterus is >Obtain written
abnormalitie hypertrophy ,
normal in size consent, particularly
s exist. The obstruction or
organs are measuring 7.7 stricture, calculus, for any ultrasound
normal in cm x 4.3 cm aneurysm, foreign procedure that
size, shape, X 3.9 cm body, vascular involves insertion of
contour and (LWT) occlusion, venous transducer into a
position. The thrombosis, body cavity or blood
*Uterine
internal atherosclerotic vessel
parechyma is
structures of plaque, abscess,
unremarkable. >The midwife
the organs congenital
No definite schedules the
and nearby anomally,
focal mass ultrasound
tissues are hematoma,
lession. examination before or
within bleeding,
several days after any
normal *Endometrial pregnancy, fetal
barium studies;
limits. stripe is not development
residual barium
thickened and
blocks the
measures
transmission of
approximately
untrasound impulses.
0.4 cm. The
cervix is >Abdominal
closed ultrasound, requires
measuring 2.0 fasting from food for
cm X 2.7 cm 12 hours
(LW). No
>Inform the patient
cervical mass
that the examination
noted.
is safe and painless
*the left
>Instruct the patient
ovary is not
not to void until after
unusual and
the test is completed.
measures 1.8
c x 2.4cm >Remove clothes,
(LWT). right jewelry and metallic
ovary objects; wear a
measures 2.4 hospital gown
cm x 2.0 cm
(LW).
adjacent to Posttest:
the right
ovary but >Remove conduction
anomaly, gel from the skin
cannot be >Assist patient to a
totally comfortable position
separated and getting dressed,
from it is an as needed
irregular
hematoma,
hyperechoic
solid mass
 measuring 4.2
cm x 3.2 cm
(LWT).

Impression:
>Right
Adnexal Solid
Mass, cannot
totally rule
out ovarian in
origin.
Normal uterus
and left
ovary.
Minimal
pelvic fluid.

X. CARE PLAN
ASSESSME DIAGNO PLANNIN MIDWIFERY RATIONALE EVALUATION/
NT SIS G INTERVENT OUTCOME
ION

Subjective: Acute pain After 8 Independent:  To determine After 8 hours of

related to hours of presence of midwife
“nasakit toy  Monitor
distension nursing hypotension interventions, the
tyan ko” (my maternal
or rupture interventio and patient was relieved
tummy vital signs
of ns, the tachcardia or controlled
hurts) as
fallopian patient will  Monitor caused by
verbalized
tube be relieved for rupture or
by the
or presence hemorrhage.
patient
controlled and
 To further
amount of
asess the
vaginal
Objectives: present
bleeding
situation
 Facial indicating
 Monitor
mask of hemorrhage.
for
pain
increase
 Increased
 Guardin and pain
pain and
g and
abdominal
behavior abdominal
distension
distension
 and indicates
rigidity. rupture and
possible
 Monitor
intraabdomin
complete
al
blood
hemorrhage.
count
(CBC)  To determine
the amount of
 Provide
blood loss
comfort
measure  Promotes
like back relaxation and
rubs, deep may enhance
breathing. patient’s
Instruct in coping
relaxation abilities by
or refocusing
visualizati attention.
on
 Diversional
exercises.
activities aids
Provide
in refocusing
diversional
attention and
activities
enhancing
 Provide coping with
diversional limitations.
activities
 To maintain
Collaborative: acceptable
level of pain
 Administer
analgesics
as
indicated
ASSESSME DIAGNO PLANNIN MIDWIFERY RATIONALE EVALUATION/
NT SIS G INTERVENT OUTCOME
ION

Subjective: Acute pain After 8 Independent:  To determine After 8 hours of

related to hours of presence of midwife
“nasakit toy  Monitor
distension nursing hypotension interventions, the
tyan ko” (my maternal
or rupture interventio and patient was relieved
tummy vital signs
of ns, the tachcardia or controlled
hurts) as
fallopian patient will  Monitor caused by
verbalized
tube be relieved for rupture or
by the
or presence hemorrhage.
patient
controlled and
 To further
amount of
asess the
vaginal
Objectives: present
bleeding
situation
 Facial indicating
 Monitor
mask of hemorrhage.
for
pain
increase
 Increased
 Guardin and pain
pain and
g and
abdominal
behavior abdominal
distension
distension
indicates
and
rupture and
rigidity.
possible
 Monitor intraabdomin
complete al
blood hemorrhage.
count
 To determine
(CBC)
the amount of
 Provide blood loss
comfort
 Promotes
measure
relaxation and
like back
may enhance
rubs, deep
patient’s
breathing.
coping
Instruct in
abilities by
relaxation
refocusing
or
attention.
visualizati
on  Diversional
exercises. activities aids
Provide in refocusing
diversional attention and
activities enhancing
  Provide coping with
diversional limitations.
activities
 To maintain
Collaborative: acceptable
level of pain
 Administer
analgesics
as
indicated

ASSESSME DIAGNO PLANNI MIDWIFERY RATIONALE EVALUATION/

NT SIS NG INTERVENTI OUTCOME
ON

Subjective: Disturbed At the end 1. Identify the  To identify At the end of 3 hours
sleeping of 3 hours presence of causative and of nursing care, the
“Rinabii nga
pattern of midwife factors that contributing patient:
dyak
related to care, the contributes to factors
makatur  Verbalized
psychologi patient disturbed
turog” as  This may understanding of
cal and will be sleeping
verbalized present an sleep disturbance
environme able to patterns.
by the additional
ntal factors  Identifies ways
patient  Verbal 2. Determine factor that
due to to promote sleep
ize recent causes the
psychologi such as making
unders traumatic event problem
cal the bed
Objective: tandin in patient’s life
(personal  To determine comfortable and
g of
 Frequent loss) and 3. Observe and usual sleep providing
sleep
yawning environme obtain feedback pattern and adequate
distur
ntal (noisy from client provide ventilation;
 Humid bance;
and regarding usual comparative
and humid)  Even though she
 Identif bedtime, baseline
noisy factors, was able to
y sleeping habits,
environ there is a  This provides verbalized ways
indivi and
ment disruption opportunity to to improve sleep
dually environmental
of the address and rest, the
 Personal appro needs when
patient’s misconceptio patient was
loss priate sleeping.
normal n and unable to report
interv
 Deep sleeping 4. Listen to unrealistic improvement in
ention
thinking pattern subjective expectations sleep pattern
s to
affecting reports of sleep since she was
 Restless promo  To determine
both quality already
te the degree of
amount discharged.
sleep; 5. Arrange care sleep
and quality and with the help of disturbance
of sleep the SO to patient feels
 Report
provide for
impro  To help client
 vemen uninterrupted achieve
t in periods of sleep optimal sleep
rest at night when and rest
and possible
 To help the
sleep
6. Assist client client
patter
emotionally properly deal
n
when loss has with the
occurred situation

XI. DRUG STUDY

DISCHARGE PLANNING
Medication
 Instruct client to continue take her prescribes medications
 Orient the client about the name of drugs, their actions, the exact dosage, the
frequency and the route of administration
 Instruct client to follow the instruction when administering medication.
 Advice the significant others not to leave the client during medications
 Explain to the client the side effects and adverse effects of the drugs she takes by
prescribing its manifestation.
 Advice client not to stop intake of prescribed medications, unless approved by the
physician.
Exercise
 Instruct client to balance activities with adequate rest periods
 Educate client on proper body mechanics to prevent muscle strain and enable
client to relax
 Encourage client to ambulate and assume normal
 Encourage deep breathing exercise
Treatment
 Educate client importance of drug compliance
 Discuss to the client the complication of the condition because knowledge about
the condition supports learning that will decrease deficit an anxiety
 To promote healing, eat a balanced diet rich in fresh fruits and vegetables
Hygiene
 Keep your incision sites clean and dry
 Do not douche or put anything in your vagina, such as a tampon, until your doctor
tells you otherwise
 Encourage client to do daily hygiene
 Encourage client to ask assistance if needed
Outpatient orders
Call the doctor if any of the following occurs:
 Develop a fever
 Become dizzy and faint.
 Experience nausea and vomiting.
 Become short of breath.
 Have heavy bleeding.
 Have leakage from the incision or the incision opens up.
 Have pain when your urinate.
 Have swelling, redness, or pain in your leg.
 Have questions about the procedure or its result
Diet
 To promote healing, eat a balanced diet rich in fresh fruits and vegetables.
Depending on how much blood loss occurred during surgery, you may require a
daily iron supplement.
 Eat high-fiber foods, drink plenty of water, and if necessary, use stool softeners.
 Instruct client to eat foods that are high in protein and vitamins and minerals.

EVALUATION
The rationale of learning during this case study was to develop an understanding of
the needs of the patients during their recovery period as well to identify the causes of
ectopic pregnancy. Student midwife would enhance their knowledge and skills; it
would also serve to update their knowledge about ectopic pregnancy; and it would
help focus their skills towards more specific patient needs.

After all the data gathering, the midwifery student Jan Audrey Galinato has been
successfully performed her task. She was able to apply her knowledge, skills, and
attitudes in caring a mother who has a case of ectopic pregnancy. She was able to
discuss the client’s personal data, family profile, past and present health history, and
physical assessment using cephalocaudal assessment, able to review the anatomy and
physiology of the female reproductive organ. Although, on the diagnostic procedure
because of uncertain reason wherein the patient’s laboratory exam results was lost
but, she gather information and search for it She was able to discussed the drug study
and develop an effective midwifery care plan in which the client may benefit and
formulated a post-partum discharge plan for the continuity of care.
Honesty ,empathy and respect are key elements for the midwife to possess. Student
midwife must develop patience, love for our work, and empathy to our patients. They
must assist in facilitating a remarkable experience as well as share our knowledge
regarding the case. They must be able to continue to study different cases and be able
to impart this to other student midwife, patients and their significant others.
REFERENCES
Pliliteri, A. Maternal and Child Health Care Nursing: Care of the Childbearing
and Children Family. 5th edition (2007) Philippines: C&E Publishing Inc.
Kozier and Erb’s Fundamentals of Nursing 8th edition
Home Edition (p. 1284). New Jersey; Merck and Co. Inc.
Nursing Pocket Guide to Diagnoses, Prioritized Interventions and Rationale
Diagnoses et.al.
Robert Berkow, MD (1997). The Merck Manual of Medical Information
https://emedicine.medscape.com/
https://www.pregnancy.com.ph/ectopic_pregnancy.htm
https://pregnancy.nci.nih.gov/pregnancytopics/types/ectopic_pregnancy
http://emedicine.medscape.com/article/1222849-overview
http://www.ectopicpregnancy.net/resources_physicians
http://www.pregnancy.org/docroot/CRI/content/CRI_2_4_2X_