FATHER SATURNINO URIOS UNIVERSITY

Butuan City
Nursing Program

A CASE STUDY
ON
NORMAL SPONTANEOUS VAGINAL
DELIVERY

BUTUAN MEDICAL CENTER

(Ob-Nursery Ward)
June 13, 2008 – July 12, 2008

In partial fulfillment
Of the requirements for the
Subject NCM 101

Submitted by:
Florence Phil H. Amoroso
BSN – III

Submitted to:
Mr. Paul Ritchie Pelos, RN
Clinical Instructor
 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 over-the-

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 mother’s 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 mother’s 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 mother’s 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 mother’s 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 mother’s 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

client’s 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 didn’t 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 doesn’t 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 P’s 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 she’d make any noise, she’d get killed. Ill-fatedly, she was held

powerless to the man, and the crime had happened. Fortunate enough that she

wasn’t 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 kaayo nako

nahimong inahan, nganong nahitabo man pud ni..” . Patient P conceived the baby

and bore it for 9 months. For the first trimester, she couldn’t 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 a having a baby unexpectedly. She even

verbalized, “Wa naman koy mabuhat. Nahitabo nato. Basin makasala pa kog

ipalaglag nako ang bata.. Wala man siya’y sala .”

According to Erik Erikson’s 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, doctor’s 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

 Abd Circ: 20 cm

Extemporaneously, the baby cried with the same breathing time of 3:36am.

Patient P’s 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 Lidocaine HCl 5cc.

 After her delivery, she was admitted to the Ob ward with repaired

episiotomy. Post partum doctor’s 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 P’s temperature was monitored until stable.

On the following day, June 30, 2008, doctor’s order was to secure HBsAg

result. Patient P’s 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 patient’s

condition. Upon assessing, I was able to take and record her vital signs:

 T = 37.3°c

 82 bpm

 21 cpm

 120/70 mmHg

Patient P wasn’t 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 akong totoy 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, doctor’s 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, doctor’s 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 mother’s 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 patient’s 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 5’4, 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 - 5th intercostals

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 – Patient’s 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 vulva—which 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 Dose Date Ordered Ordering Physician

Cephalexin 500mg 1 cap June 29, 2008 Dr. Bombeo

TID

Mefenamic Acid 500mg 1 June 29, 2008 Dr. Bombeo

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 taking medication

 Caution patient that drug can cause dependence

PROBLEM LIST
 Problem # Nursing Diagnosis Date Identified Date Evaluated

1 Risk for infection r/t June 30, 2008 July 1, 2008

traumatized skin

tissue 2º to

episiotomy

2 Interrupted breast July 1, 2008 July 1, 2008

feeding r/t infant

illness

3 Situational Low Self- July 1, 2008 Not Evaluated

Esteem r/t perceived

failure at life events

2º to rape trauma

LEARNING OUTCOMES

For at least four weeks of duty, I have encountered several constraints

with regards to the implementation of interventions. It was not that easy specially
that what I am dealing with are lives, lives through which if jeopardized, can either

put me in an obnoxious situation or be blameworthy for any complications.

Three days of multi-tasking and time management, the OB-NURSERY

ward exposure has taught me how to appropriately handle pregnant and post

partum women. The idea of caring for mothers and newborns which is not in my

lineage is hard. Hard, because some of the patient’s are uncooperative and non

compliant. It isn’t that smooth to establish an interacting relationship specially that

most of the patient’s admitted in the institution has a low educational attainment.

Therefore, I cannot expect them to fully comprehend the instructions I have

imparted. However, it was a marvelous experience since I was exposed to various

kinds of maternal paragons and procedures which weren’t return demonstrated yet.

Fortunately, there is our clinical instructor who persistently supervised us and

assisted us to make it through with just minimal errors.

Now, let me get this straight. This is my first time to manage an

individual case study. Adding to that is the fear of making a physiologic structure of

my opted case. One false move and I am screwed. I have learned to thoroughly

assess my patient to comply with the requisites. Also, I have acquainted myself with

regards to establishing rapport with my patient to have a trusting relationship. Some

patients do not totally disclose themselves because they may find it privacy invading.

I have learned to be patient and control my feelings of anger or annoyance towards

the patient; to respect and accept their beliefs and values without judging them; to

communicate with them therapeutically; to be accurate and systematic when it

comes to charting to avoid errors and reprimands. Basically, it’s the feeling of

confidence you have in yourself that will facilitate accomplishment and error-free

implementation of nursing care. If you are confident enough to perform the

procedures, then the client will develop trust and confidence to you. The nurse has a

lot of responsibilities to take in, thus, confidence is a very important factor.

 The exposure wasn’t centered mainly to rendering care. It was also

focused to building and developing intrapersonal and interpersonal relationships. I

call it, personal growth. To adjust and adapt with the environment is a humongous

task! It’s not that easy. But mingling with other people helps you identify your

strength and weaknesses, and it aids in modifying what is somehow negative in our

attitudes. To sum this all up, it was a SUCCESS! Thanks be to GOD.

The next time that I’ll render care and perform procedures, I will try

to do my best to attain satisfaction and accomplishment.

ACKNOWLEDGEMENT

The materialization of this case study wouldn’t be possible without the

aid of the following folks:

 To the Almighty Father for the strength given in realizing and fulfilling

the duties and the study; to beloved parents who have always been supportive all

throughout the start of the duty until the end, the toils and efforts; to dear

comrades and colleagues who have been extending all out help during the rough

scenarios, specially to Miss Sheila Marie Adorador for aiding me in realizing the case

study; and to my groupmates for the overwhelming support, help and

camaraderie, for being cooperative and indulging, that helped me

augment my learning and somehow sharpened my skills.

To our ever lenient but strict clinical instructor, Mr. Paul Ritchie Pelos,

for simplifying what used to be incomprehensible, tricky and complicated

concepts, for assisting us in the various procedures we have performed,

and for being kind to us despite our immaturity