A CASE STUDY

ON
NORMAL SPONTANEOUS VAGINAL
DELIVERY

INTRODUCTION

Pregnancy, the state of carrying a developing embryo or fetus within

the female body. This condition can be indicated by positive results on an overthe-counter urine test, and confirmed through a blood test, ultrasound,
detection of fetal heartbeat, or an X-ray. Pregnancy lasts for about nine months,
measured from the date of the woman's last menstrual period (LMP). It is
conventionally divided into three trimesters, each roughly three months long.

When gestation has completed, it goes through a process called

delivery, where the developed fetus is expelled from the mothers womb. There
are two options of delivery: Cesarean section and NSVD or normal spontaneous
vaginal delivery. A cesarean section is a surgical incision through the mothers
abdomen and uterus to deliver one or more fetuses. NSVD or normal
spontaneous vaginal delivery is the delivery of the baby through vaginal route. It
can also be called NSD or normal spontaneous delivery, or SVD or spontaneous
vaginal delivery, where the mother delivers the baby with effort and force
exertion.

Normal labor is defined as the gradual subjugation and dilatation of

the uterine cervix as a result of rhythmic uterine contractions leading to the

expulsion of the products of conception: the delivery of the fetus, membranes,

umbilical cord, and placenta. Laboring cannot that be easy; thereby implicating
that there are processes and stages to be undertaken to achieve spontaneous
delivery. Through which, Obstetrics have divided labor into four (4) stages
thereby explaining this continuous process.

STAGE 1: It is usually the longest part of labor. It begins with

regular uterine contractions and ends with complete cervical dilatation at 10
centimeters. This stage is broken down into three (3) phases: the Early phase,
where the contractions are usually very light and maybe approximately 20
minutes or more apart from the beginning, gradually becoming closer, possibly
up to five minutes apart; the Active phase, where contractions are generally four
or five times apart, and may last up to 60 seconds long. Cervix dilates with 4-7
cm and initiates a more rapid dilatation. It is known that to get through active
labor, mobility and relaxations are done to increase contractions; and the
Transition phase, where it is definitely known as the shortest phase but the
hardest, contractions maybe two or three times apart, lasting up to a minute
and a half, about approximately 8-10 cm of cervical dilatation. Some women will
shake and may vomit during this stage, and this is regarded as normal. Most of
the time, women would find a comfortable position to acquire complete
dilatation.

STAGE II: This stage lasts for three or more hours. However, the
length of this stage depends upon the mothers position (e.g.; upright position
yields faster delivery). Once the cervix has completely dilated, the second stage
had begun. This stage ends with the expulsion of the fetus.

STAGE III: This stage focuses on the expulsion of the placenta from
the mother. Placenta exclusion is much more easier than the delivery of the
baby because it includes no bones, and this is during this stage that the baby is
placed on top of the mothers womb.

STAGE IV: No more expulsions of conception products for this stage

as this is generally accepted as POST PARTUM juncture. This phase is from the
placental delivery to full recovery of the mother.

Labor and delivery of the fetus entails physiological effects both on

the mother and the fetus. In the cardiovascular system, the mothers cardiac
output increases because of the increase in the needed amount of blood in the
uterine area. Blood pressure may also rise due to the effort exerted by the
mother in order expel the fetus. There could also be a development of
leukocytes or a sharp increase in the number of circulating white blood cells
possibly as a result of stress and heavy exertion. Increased respiratory may also

occur. This happens as a response to the increase in blood supply in order to

increase also the oxygen intake.

Braxton Hicks contractions, or also known as false labor or practice

contractions. Braxton Hicks are sporadic uterine contractions that actually
start at about 6 weeks, although one will not feel them that early. Most women
start feeling them during the second or third trimester of pregnancy. True labor
is felt in the upper and mid abdomen and leads to the cervical changes that
define true labor.

With delivery imminent, the mother is usually placed supine with her
knees bent (ie, the dorsal lithotomy position). An episiotomy (an incision
continuous with the vaginal introitus) may be performed at this time. Episiotomy
may ease delivery of the fetal head and allow some control over what may
otherwise be an uncontrolled perineal laceration. However, many providers no
longer perform routine episiotomy, since it may increase the risk of rectal injury
and are larger than the spontaneous laceration.

The labor and birth process is always accompanied by pain. Several

options for pain control are available, ranging from intramuscular or intravenous
doses of narcotics, such as Meperidine (Demerol), to general anesthesia.

Regional nerve blocks, such as a pudendal block or local infiltration of the

perineal area can also be used. Further options include epidural blocks and
spinal anesthetics.

Nursing Health History

Nursing health history is the first part and one of the most significant
aspects in case studies. It is a systematic collection of subjective and objective
data, ordering and a step-by-step process inculcating detailed information in
determining clients history, health status, functional status and coping pattern.
These vital informations provide a conceptual baseline data utilized in
developing nursing diagnosis, subsequent plans for individualized care and for
the nursing process application as a whole.

In keeping the private life of my patient and in maintaining confidentiality,

let me hide for with the pseudonym of Patient P.

Patient P was born on December 19, 1992. She was born to parents from
Surigao Del Norte, but she didnt actually live with them. She was technically
abandoned to the relatives, but those people could not essentially foster her.
She stayed at the Department of Welfare and Social Development or DSWD and
spent her 15 years of existence. Her education was funded mainly by volunteers
and charitable foundations. At the same time, she compensated for it by means
of helping in chores and accomplishing tasks in the said foundation.

She grew up with other abandoned children with questions in her mind.
But to that, she never completely disclosed herself. Patient P is a victim of
sexual abuse. She was raped and was unable to resist because of her innocence.
She doesnt talk that much. Often times, she paces back and forth inside the
ward, sits silently on her bed and sometimes quietly stares outside the window.
When tried to ask about what she knows of her family, she could only turn silent,
and somehow implies to ask the next question to her. But when chance
punched, I grasped it and coiled directly to my point. Unfortunately, hesitancy
was felt from the kind of thing that was wanted to be discussed. The issue was
not forced until her watcher, which has no relation to her, revealed the reason
behind her pregnancy.

According to Patient Ps watcher, it was on a cold night in September

2007, when Patient P came home from school: Upon nearing the center, a man,
which she identified as a newcomer to the center, blocked and harassed her
brutally. She struggled to let go from the ruthless hands of the unaccustomed
man. Patient P was threatened that if shed make any noise, shed get killed. Illfatedly, she was held powerless to the man, and the crime had happened.
Fortunate enough that she wasnt killed, she thanked the Lord for sparing her
life. Although alive, she felt very much unfair about her situation. She could only
tell, Kabata pa kaayonakonahimonginahan, nganongnahitabo man pudni...
Patient P conceived the baby and bore it for 9 months. For the first trimester,
she couldnt believe and accept her fate, and sometimes thought of slight
curses to the person who did the crime. But somehow, she felt a jot of
excitement

of

having

Wanamankoymabuhat.

baby

unexpectedly.

Nahitabonato.

Basin

She

even

verbalized,

makasala

pa

kogipalaglagnakoangbata..Wala man siyaysala.

According to Erik Eriksons Developmental Task of adolescence, from the

age of 10 to 18 years old, Patient P belonged to the IDENTITY versus ROLE
CONFUSION, which proposes that the adolescent is newly concerned with how
he or she appears to others. Development mostly depends upon what is done
to us. From here on out, development depends primarily upon what we do.
And while adolescence is a stage at which we are neither a child nor an adult,

life is definitely getting more complex as we attempt to find our own identity,
struggle with social interactions, and grapple with moral issues.

On June 29, 2008, Patient P complained of extreme abdominal pain. On

the same date was her EDC or expected date of confinement. The age of
gestation is 39 weeks by LMP. Her LMP was September 2007, exact date
unrecalled. She was admitted to Butuan Medical Center at around 2:40am with
blood pressure of 140/90 mmHg. She was examined by Dr. Bombeo and found
out that she was fully dilated. By 2:45am, 5 minutes after her admission,
doctors orders were carried out:

#1 D5LR I Liter started @ 20 gtts/min

TPR q 4

NPO

CBC blood typing; hbsAg requested

Labor watch

By 2:55am, she was endorsed to DR wheelchair. With the next 5 minutes,

she was admitted in the ER accompanied by the staff, positioned on the DR
table with final preparation done.

Around 3:36 am, she delivered an alive, 6 lbs 13 oz and 49 centimeters in

length baby girl with these statistics:

Head Circ:

32 cm

Chest Circ:

30 cm

AbdCirc:

20 cm

Extemporaneously, the baby cried with the same breathing time of

3:36am. Patient Ps placenta was expelled spontaneously by 3:47am with blood
pressure of 130/80. Oxytocin 10 units was infused to IVF; Methergine I amp IVTT;
her uterus was firm and contracted and was admitted to ward via stretcher.
During her labor, she was anesthetized with LidocaineHCl 5cc.

After her delivery, she was admitted to the Ob ward with repaired
episiotomy. Post partum doctors orders were as follows which was carried out:

DAT (Diet as Tolerated)

Ice pack over hypogastrium

Perineal care

Oxytocin 10 U infused to IVF and;

Methergine I amp IVTT.

Cephalexin I amp IVTT

Mefenamic Acid 500mg I cap TID

May room in

Breastfeed per demand

Patient Ps temperature was monitored until stable.

On the following day, June 30, 2008, doctors order was to secure HBsAg
result. Patient Ps baby was admitted to NICU because of frequent vomiting and
fever. The staff continued to monitor her vital signs and administered prescribed
medications. As a student nurse, I also did my assessment towards my patients
condition. Upon assessing, I was able to take and record her vital signs:

T = 37.3c

82 bpm

21 cpm

120/70 mmHg

Patient P wasnt able to take a bath because of her beliefs. Since she has
an episiotomy wound, she is at risk for infection. I made my independent
nursing interventions. I explained to her the importance of proper hygiene to
prevent the occurrence of infection. Emphasis on eating foods rich high protein
to promote wound healing was imparted. She verbalized, Sakit man akongtotoy
mam. So, I encouraged her to let her baby continuously suck to both breasts
when received back from NICU, that is to relieve her engorgement. Also, I
instructed her to increase fluid intake at least 8 oz per hour to facilitate increase

in milk production, and to eat nutritious foods such as fruits and vegetables to
nourish her baby well.

On July 1, 2008, doctors orders were noted:

Continue meds

Repeat hemoglobin

MGH after IE and if hemoglobin is OK

By 1:25 pm:
Defer MGH

Secure and transfuse 4 units FWB/wg (fresh whole

blood) properly crossmatched
Antamine I amp 10,000 units

BT (blood transfusion)

On the same day, I did my Physical assessment to Patient P and a brief

history about her case. I aided her in securing her blood by persistently going
with her to the blood bank. Patient P was advised to take adequate rest in fear of

hypotension due to her low hemoglobin, 59G/L. So, it was me and her watcher
who was always on the go. I continued to administer her medications per
prescription:

Cephalexin 500mg I cap TID

Mefenamic Acid 500mg I cap TID

July 2, 2008, doctors order was to follow up 4 units of blood. Patient P was
reinserted with IV D5LR.
On July 7, 2008, Patient P was transfused with 4 units of fresh whole
blood, baby was already on mothers side, and were about to go home. She was
seen with the health workers facilitating her discharge from the hospital.

PHYSICAL ASSESSMENT

Physical examination follows a methodical head to toe format in the

Cephalocaudal assessment. This is done systematically using the techniques of
inspection, palpation, percussion and auscultation with the use of materials and
investments such as the penlight, thermometer, sphygmomanometer, tape
measure and stethoscope and also the senses. During the procedure, I made
every effort to recognize and respect the patients feelings as well as to provide
comfort measures and follow appropriate safety precautions.

A. General Physical Assessment

Patient is a 15 year old female, stands 54, with pulse rate of 82 beats pre
minute, respiratory rate of 21 breathe per minute and a temperature of 37.3 C.
She is conscious and coherent upon interaction but answers only the questions

she is comfortable with. Most of the time, she is pacing inside the ward and
appears withdrawn.

B. Assessment of the Head

Head is round in shape. Hair is long, thick and coarse, straight and evenly
distributed. Scalp is smooth and white in color, minimal lesions were noted.
Dandruff and lice were seen.

C. Assessment of the Eyes

Her eyes are symmetrical, black in color, almond shape. Pupils constricts
when diverted to light and dilates when she gazes afar, conjunctivas are pink.
Eyelashes are equally distributed and skin around the eyes is intact. The eyes
involuntarily blink.

D. Assessment of the Ears

Ears are clean, no ear wax was noted and approximately of the same size
and shape. Patient can hear normally when spoken softly.

E. Assessment of the Nose

With narrow nose bridge, there were discharges noted upon inspection. No
swelling of the mucous membrane and presence of nasal hairs were seen.

F. Assessment of the Mouth

She has a complete set of teeth with minimal dental caries noted. Oral
mucosa and gingival are pink in color, moist and there were no lesions nor
inflammation noted. Tongue is pinkish and is free of swelling and lesions. Lips
are symmetrical, appears pale without bits noted upon observation.

J. Assessment of the Neck

Lymph nodes noted. Neck has strength that allows movement back and
forth, left and right. Patient is able to freely move her neck.

H. Assessment of the Lungs and Thoracic Region

No reports of pain during the inhalation and exhalation. Absence of

adventitious sounds upon auscultation. Respiratory rate 21 breathes per minute
from the normal range of 16-20 breaths per minute.

I. Assessment of the Heart

Patient has an audible heart sound. PMI is heard between 4 th 5thintercostals space. Heart is pumping well with a pulse rate of 82 bpm from the
normal rate of 60-100 beats per minute.

J. Assessment of the Abdomen

Abdominal movement as with respiration, presence of peristalsis during

auscultation.Presence of rashes and lesions.

K. Assessment of the Upper Extremities

Skin: White in color; presence of marks/scars of wounds in the

arms, neck and legs. Skin is smooth, moist and soft to touch.

Hands: Medium in size with 5 fingernails in each side. Nails are

short, small dusty particles are present.

Arms: Able to move through active ROM. Able to extend arms in

front or push them out to the side.

L. Assessment to the Lower Extremities

Size of the feet is undefined with lines on the sole, presence of scars and
lesions. Ten fingers are present. Nails are clean and short. Patient is ambulatory.

M. Assessment of the Genitourinary

With episiotomy dry and intact, urinates 2-4 times a day and has not
defecated yet since her delivery.

N. Assessment of the Perineum

With episiotomy intact, absence of lesions and swelling.

O. Neurological Assessment

Behavior

Patient is silent but is conscious and coherent

upon interaction. She sits and walks if she wants to.

Motor Functioning -

Able to move extremities

through active ROM. Able to extend arms front and

resist active as pushed down/up on his hands.

Reflexes -

reflexes were present such as the blinking reflex

and deep tendon reflex.

Sensory Functioning Patients sensory system is intact,

she was able to distinguish touch, pain, hot and cold.

ANATOMY AND PHYSIOLOGY OF THE REPRODUCTIVE SYSTEM

EXTERNAL GENITALIA

Our overview of the reproductive system begins at the external genital

area or vulvawhich runs from the pubic area downward to the rectum. Two
folds of fatty, fleshy tissue surround the entrance to the vagina and the urinary
opening: the labia majora, or outer folds, and the labia minora, or inner folds,
located under the labia majora. The clitoris, is a relatively short organ (less
than one inch long), shielded by a hood of flesh. When stimulated sexually, the

clitoris can become erect like a man's penis. The hymen, a thin membrane
protecting the entrance of the vagina, stretches when you insert a tampon or
have intercourse.

INTERNAL REPRODUCTIVE STRUCTURE

The Vagina
The vagina is a muscular, ridged sheath connecting the external genitals
to the uterus, where the embryo grows into a fetus during pregnancy. In the
reproductive process, the vagina functions as a two-way street, accepting the
penis and sperm during intercourse and roughly nine months later, serving as
the avenue of birth through which the new baby enters the world .
The Cervix
The vagina ends at the cervix, the lower portion or neck of the uterus. Like
the vagina, the cervix has dual reproductive functions.
After intercourse, sperm ejaculated in the vagina pass through the cervix,
then proceed through the uterus to the fallopian tubes where, if a sperm
encounters an ovum (egg), conception occurs. The cervix is lined with mucus,
the quality and quantity of which is governed by monthly fluctuations in the
levels of the two principle sex hormones, estrogen and progesterone.
When estrogen levels are low, the mucus tends to be thick and sparse,
which makes it difficult for sperm to reach the fallopian tubes. But when an egg
is ready for fertilization and estrogen levels are high the mucus then becomes
thin and slippery, offering a much more friendly environment to sperm as they
struggle towards their goal. (This phenomenon is employed by birth control pills,
shots and implants. One of the ways they prevent conception is to render the
cervical mucus thick, sparse, and hostile to sperm.)

Uterus
The uterus or womb is the major female reproductive organ of humans.
One end, the cervix, opens into the vagina; the other is connected on both sides
to the fallopian tubes.
The uterus mostly consists of muscle, known as myometrium. Its major
function is to accept a fertilized ovum which becomes implanted into the
endometrium, and derives nourishment from blood vessels which develop
exclusively for this purpose. The fertilized ovum becomes an embryo, develops
into a fetus and gestates until childbirth.
Oviducts
The Fallopian tubes or oviducts are two very fine tubes leading from the
ovaries of female mammals into the uterus.
On maturity of an ovum, the follicle and the ovary's wall rupture, allowing
the ovum to escape and enter the Fallopian tube. There it travels toward the
uterus, pushed along by movements of cilia on the inner lining of the tubes. This
trip takes hours or days. If the ovum is fertilized while in the Fallopian tube, then
it normally implants in the endometrium when it reaches the uterus, which
signals the beginning of pregnancy.
Ovaries
The ovaries are the place inside the female body where ova or eggs are
produced. The process by which the ovum is released is called ovulation. The

speed of ovulation is periodic and impacts directly to the length of a menstrual

cycle.
After ovulation, the ovum is captured by the oviduct, where it travelled
down the oviduct to the uterus, occasionally being fertilised on its way by an
incoming sperm, leading to pregnancy and the eventual birth of a new human
being.
The Fallopian tubes are often called the oviducts and they have small
hairs (cilia) to help the egg cell travel.

DRUG LIST

Drug Name and

Date Ordered

Ordering Physician

June 29, 2008

Dr. Bombeo

June 29, 2008

Dr. Bombeo

Dose

Cephalexin 500mg 1
cap TID

Mefenamic Acid 500mg

1 cap TID

DRUG STUDY
(ORAL MEDS)

GENERIC NAME: CEPHALEXIN

CLASSIFICATION: Anti-Infective
ACTION: Inhibits DNA synthesis by inhibiting DNA gyrase in
susceptible gram negative and gram positive organisms

INDICATIONS: Infectious diarrhea, respiratory tract infection,

infection on the skin structures, bones and joints
CONTRAINDICATIONS:

Hypersensitivity to drug or other

fluoroquinolones
ADVERSE REACTIONS:
CNS: Headache

CV: Orthostatic Hypotension

EENT: Blurred Vision

GI: Nausea and Vomiting, Diarrhea, constipation

OTHER: Taste

INTERACTIONS: Oral anticoagulants: Increased anti-coagulant effects

NURSING CONSIDERATIONS:
Advise

Patient

not

to

take

drugs

with

dairy

or

Caffeinated products
Inform physician if allergies or rashes abruptly develop

GENERIC NAME: MEFENAMIC ACID

CLASSIFICATION: Anti-Inflammatory, Analgesic
ACTION: Inhibits reuptake of serotonin norepinephrine CNS
INDICATIONS: Moderate to moderately severe pain
CONTRAINDICATIONS: Hypersensitivity with drugs, acute
intoxication with alcohol, physical opioid dependence
ADVERSE REACTIONS:
CNS: dizziness

CV: Vasodilation

EENT: visual disturbances

GI: Nausea and Vomiting

GU: urinary retention

SKIN: pruritus

NURSING CONSIDERATIONS:

Tell patient that drug works best when taken before pain
becomes severe
Recommend

abstinence

from

alcohol

when

medication
Caution patient that drug can cause dependence

PROBLEM LIST

taking

Nursing

Date

Date

Diagnosis

Identified

Evaluated

Risk for infection r/t

June 30, 2008

July 1, 2008

July 1, 2008

July 1, 2008

July 1, 2008

Not Evaluated

Problem #

traumatized skin
tissue 2 to
episiotomy

Interrupted breast
feeding r/t infant
2

illness

Situational Low
Self-Esteem r/t
perceived failure at
3

life events 2 to
rape trauma

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