A CASE STUDY ON NORMAL SPONTANEOUS VAGINAL DELIVERY

Prepared by:
Zenyjean Gallegos
Margie Orlina
Angelica Wee
Shera Salinog

Submitted to:
Ms. Kissie Largo, RN
 March 1, 2019

INTRODUCTION

Pregnancy is the term used to describe the period in which a fetus develops inside a woman's womb or uterus.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 usually lasts about 40 weeks, or just over 9 months, as measured from the last menstrual period to delivery. 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 spontaneous vaginal delivery is the commonest mode of delivery globally, particularly in remote areas of resource
constrained countries where modern healthcare is limited. Conditions that may prevent natural delivery or make it difficult
include cephalopelvic disproportion, fetal distress, abnormal presentations and other medical conditions. According to a study
here in the Philippines, 85% of Filipino women prefer normal vaginal deli very while 15% preferred delivery by elective
caesarean section (CS).
Nursing Health History
 PHYSICAL ASSESSMENT

A. General Physical Assessment

Patient is a year old female, stands 5’4,with pulse rate of 82bpm, respiratory rate of 21cpm 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ward and appears withdrawn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 constrict 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.
G. 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.
J. Assessment of the Abdomen
Abdominal movement as with respiration, presence of peristalsis during auscultation. Presence of rashes and lesions.K.
K. Assessment of the Upper Extremities
Skin
Light brown 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.
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.
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.
N. Assessment of the Perineum
With episiotomy intact, absence of lesions and swelling..
O. Neurological Assessment
– 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.
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 PHYIOLOGY 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 thevagina; 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 that 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 ciliaon 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 calledovulation.
The speed of ovulation isperiodic and impacts directly to the length of a menstrual cycle.
After ovulation, the ovum is captured by theoviduct, where it travelled down the oviduct to the uterus, occasionally beingfertilisedon its way by
an incomingsperm, leading topregnancyand 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.
ACKNOWLEDGEMENT
PATHOPHYSIOLOGY (Normal Spontaneous Vaginal Delivery)

HOST AGENT ENVIRONMENT

Female Therapeutic Environment
___ yrs old FERTILIZATION
G (union of sperm and ovum)
T
P Zygote-Unicellular
A (intermingling of haploid paternal 23 X or Y and maternal 23 X chromosome)
L
Series of mitotic cell division - Cleavage
(in 24 hrs it became two cell organism)

In 72 hours it became 16 cell organism called Morula

Morula enters the uterus on the 3rd day through peristaltic movement

Separates into two parts by fluid on the uterus on the 4th day

The outer layer give rise to the placenta The inner layer give rise to the embryo
(trophoblast) (embryoblast)

3 stages Blastocytes attaches to the endometrium on the 6th day

st
1 stage- increase in cell number with elaboration of cell products
2nd stage- morphogenesis / includes mass cell movement Implantation
3rd stage- differentiation or maturation of physiologic processes
Embryonic development begins during 2nd week continues through the 8th week

Fetal development is from 9th week to birth

Newborn via vaginal delivery
 Nursing Care Plan

ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Independent
Disturbed Short term: After 4 hrs. of
sleeping pattern holistic nursing care,
“Di ko katulog ky 1. Position client in a 1. To alleviate discomfort
related to pain patient was able to:
puros sakit sa lawas comfortable position
and discomfort After 4 hrs. of holistic
ako mabatian”
on perineum nursing care, patient 2. Provide comfort measures
secondary to 2. To distract attention on
will be able to: ( dim light, light music) -Report decreased
labor and pain, reduce tension and to
feeling of discomfort
Objective: delivery. promote
as manifested by
nonpharmacological pain
-Report decreased verbalizing feeling of
management
feeling of discomfort comfort (5/10)
 Tirediness
as manifested by
 Frequent verbalizing feeling of 3. Assess sleep pattern
3. To provide comparative
yawning comfort (5/10) -Achieve atleast 5-6
baseline
hrs of sleep
 Overall
body malaise
-Achieve atleast 5-6
4. Encourage the client to 4. Verbalizing concerns may -Show
 Pain (7/10) hrs of sleep signs of
express concerns when promote relaxation decreased yawning
 Dark circle unable to sleep
around the eyes
-Show signs of 5. Provide a warm bath
5. Vasodilation of the veins
decreased yawning before the client goes to -Report decreased
provide a sleepy lazy effect
sleep body malaise

6. Expose perineum on
-Report decreased
perilight bid for 15 mins. 6. To provide comfort
body malaise UNMET.

Dependent
Long term: Long term:
After 2 days. of 1. Prescribe sedatives as After 2 days. of
holistic nursing care, ordered (Valium) holistic nursing care,
1. To induce sleep
patient will be able to: patient will be able
to:

-reestablish and
maintain normal sleep -reestablish and
pattern maintain normal
sleep pattern

-achieve 7-8 hours of

sleep per day -achieve 7-8 hours of
sleep per day

-report absence of
body malaise -report absence of
body malaise

-report further
alleviation of pain -report further
(3/10) alleviation of pain
(3/10)

-absence of frequent
yawning -absence of frequent
yawning

UNMET.
 ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: INDEPENDENT
Anxiety related Short term: After 4 hrs. of
to hospitalization holistic nursing care,
Client verbalized 1. Monitor vital signs 1. To obtain baseline data
and upcoming patient was able to
concern about her
delivery process After 4 hrs. of holistic 2. Asses level of anxiety 2. Identify areas of concern manage anxiety with
upcoming delivery
nursing care, patient through verbal and non that might interfere with the positive coping
and expresses
will be able to manage verbal cues normal progress of labor mechanisms as
worries about the
anxiety with positive evidenced by:
child inside her 3. Employ and calm, caring, 3. Enhances nurse-client
coping mechanisms as
womb. confident, non judgemental relationship
evidenced by:
 approach -acknowledgement
and discussion of
Objective: -acknowledgement 4. Allow client to express 4. Provides a healthy outlet
fears, recognizing
and discussion of fears and feelings of anxiety of emotions and relieves
unhealthy vs.
fears, recognizing appropriately anxiety
Healthy fears
 Exhibit unhealthy vs. Healthy
5. Acknowledge normalcy 5. Adequate explaination
poor eye contact fears
of fear and provide helps reduce anxiety , soothe
 Facial oppurtunity for questions fears and provides assurance - absence of facial
tension observed and asnwer honestly within tension and improved
- absence of facial
clients level of attention span
 Impaired tension and improved
understanding
attention noted attention span
6. Offer support by staying
 Appears with the patient
- verbalizes control
preoccupied; 6. Provides feeling of of the situation
- verbalizes control of
decreased security and trust between
the situation
perceptual field the nurse and patient
DEPENDENT
-verbalizes desire to
participate in labor
-verbalizes desire to
process as tolerated
participate in labor Administer anti anxiety
process as tolerated medication as ordered by the Mechanism of action is to
physician relieve anxiety
- expresses
confidence in
- expresses confidence
herself , her support
in herself , her support COLLABORATIVE
person and the
person and the
healthcare personnel
healthcare personnel
Refer to support group
(Families and Friends)
- Acquires knowledge Provides ongoing and timely - Acquires
support knowledge about
about childbirth and is
childbirth and is
better prepared to cope
with future births better prepared to
cope with future
births

GOAL UNMET.
 ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: INDEPENDENT
Altered Comfort: After 4 hrs. of holistic After 4 hrs. of
Pain related to nursing care, patient holistic nursing care,
Client was 1. Assess the degree of pain 1. Provide baseline data for
bearing down shall actively patient was able to
frequently shouting and its characteristics , future interventions
efforts and participate in labor and actively participate in
and moaning. location, severity and
distention of the cope with the labor and cope with
Reported slight duration and frequency.
perineum discomfort effectively the discomfort
difficulty in bearing
as evidenced by: 2. Employ a calm, caring, effectively as
down.
confident, non judgemental 2. Enhances nurse-client evidenced by:
approach relationship
-Verbalize pain within
Objective: 3. Accept patients
tolerable limits -Verbalize pain
description of pain
-Verbalize desire to 3. Pain is subjective and within tolerable
4. Support pt. Pain coping cannot be felt by others limits
 Sighing continue with the labor
activities: Offer support by
and moaning process 4. Provides a sense of trust -Verbalize desire to
staying with the patient ,
observed
pating her arms and and security between the continue with the
nurse and client. labor process
 Facial brushing her hair.
-Perceive labor
tension and
experience in a 5. Instruct patient to do
grimacing noted
positive light and proper breathing technique. -Perceive labor
 Restlessne comply with the experience in a
ss observed instructions of the 5. It prevents exhaustion positive light and
physician effectively therefore preventing comply with the
 Profuse prolonged delivery of the instructions of the
sweating noted fetus and prolonged pain. physician effectively
-Demonstrate use of COLLABORATIVE
relaxation and
diversional activities -Demonstrate use of
such as guided relaxation and
Participate in the delivery
imagery and deep diversional activities
process together with the
breathing To minimize workload, such as guided
healthcare team.
therefore saving time and imagery and deep
making the delivery of the breathing
-Demonstrate proper fetus faster.
breathing techniques
-Demonstrate proper
breathing techniques

GOAL UNMET.