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I. INTRODUCTION

Pregnancy is defined as a state of carrying a developing embryo or fetus within the

female body. When the growth and development of the fetus is completed, it undergoes
the process of delivery. There are two types of delivery, normal spontaneous vaginal
delivery and caesarean. Normal spontaneous vaginal delivery is the most common way to
deliver a baby and is defined as a gradual effacement of the vagina, dilatation of the
uterine cervix as a result of rhythmic uterine contractions leading to the expulsion of the
products of conception, while caesarean section, is a surgical incision through a mothers
abdomen and uterus to deliver one or more fetuses.

This care study focuses on the mother and the nursing care given to her, which she
gave birth to her first baby boy under normal spontaneous vaginal delivery. I have chosen
the case of S, J. C. because her case is common among all women.

I want to broaden my knowledge and enhance my nursing skills and ahve a positive
attitude towards NSVD patients in caring. As a student nurse, it is my duty and
responsibility to render proper care and management to my patients.
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II. GENERAL DATA

NAME: S, J. C.

AGE: 35 y.o.

SEX: FEMALE

CIVIL STATUS: Married

ADDRESS: Alang – Alang, Mandaue City

PLACE OF BIRTH: Guihulgon, Negros Oriental

CITIZENSHIP: Filipino

RELIGION: Roman Catholic

DATE OF ADMISSION: September 24, 2010

HOSPITAL ADMITTED: VCMC

BIRTHDAY: February 19, 1978

ROOM #: 220 – 2

IMPRESSIONS: G1P1, Pregnancy uterine, 38 4/7 weeks. Elderly Primigravida

ATTENDING PHYSICIAN: Dr. Camarote

FINAL DIAGNOSIS: G1P1, pregnancy uterine, cephalic delivered, normal

spontaneous vaginal delivery, term birth, live baby
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III. HISTORY OF PRESENT ILLNESS

In the morning, patient noted irregular contractions, no vaginal discharge noted, in

scheduled PNCU, she was 5 -6 cm, effaced and advised for admission.

IV. PAST HEALTH HISTORY

Patient is non-asthmatic, non-alcoholic, and non-hypertensive. Has no previous

hospitalizations, no drug allergies and no known food allergies.

Patient had her menarche at 14 y.o. with regular monthly menstrual cycle, lasting for
4 days, consuming 2 – 4 pads / day. Has history of dysmenorrhea. First sexual contact
was at 32 y.o. with one sexual partner. No illness occurred during the entire course of
pregnancy.

V. FAMILY, PERSONAL, SOCIAL AND ENVIRONMENTAL HISTORY

The importance of studying the family history of the patient was to identify the past
and present illness or complications that the patient had as her family and the underlying
heredo-familliar disease that affect to the patients health status.

A.MEMBERS OF IMMEDIATE FAMILY / FAMILY HISTORY

The type of family they have is a nuclear family, wherein it is composed of father,
mother and siblings. The patient is the third and thy only are two sisters in the family
with 5 brothers.

NAME AGE SEX POSITION IN EDUCATIONAL

THE ATTAINMENT
FAMILY
C, J. 61 MALE FATHER High School
Graduate
C, B. Z. 60 FEMALE MOTHER High School
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Graduate
C, N. 41 MALE Eldest CHILD High School
Graduate
C, P. 38 MALE 2ND CHILD High School
Graduate
C, J. 35 FEMALE 3RD CHILD High School
Graduate
C, T. 31 MALE 4TH CHILD High School
Graduate
C, C. 29 MALE 5TH CHILD High School
Graduate
C, J. 26 MALE 6TH CHILD High School
Graduate
C, J. 23 FEMALE Youngest High School
CHILD Graduate

B. PERSONAL AND SOCIAL HISTORY

The patient wakes up 7 o’clock in the morning, usually she prepares breakfast, she
eats milk and bread. During lunch and dinner she usually eats rice, fish, meat and
vegetables. She eats right on time every meals, never skips a meal. She eats at home and
her husband brings her fruits to eat. She takes vitamins and she has complete teeth, no
missing, she drinks water 6 – 8 glasses a day.

She is a plain housewife, she usually cooks food, does the dishes but apparently she is
helped by her mother and young sister. They do together the laundry and ironing the
clothes and cleanse the house. Most of the time she relaxes and takes a break to rest.
They watch TV every after lunch and sleeps in the afternoon. They usually pray together
with her family and help on her exercises. She has regular sleep except when urinating
early in the morning. Her routine naps are from 9am to 11am and 3pm to 5pm.

The patient sees herself as positive and is happy for her baby to come. She states that
it is normal to have a baby and is excited about it.

C. ENVIRONMENTAL HISTORY
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Patient lives in Alang-alang, Mandaue City, in a compound where they rented. The
house has one room, one rest room, and one living room. They only walk when going to
church and barangay hall. Water supply is from Metro cebu water district and electricity
supply is from Visayas electric company. Their market is at a walking distance and so is
their grocery store. Their place is peaceful and people around them are kind and happy
with them.

VI.NURSING REVIEW OF SYSTEM AND PHYSICAL ASSESMENT

OBJECTIVE SUBJECTIVE

HEAD

. Symmetrical facial features, hair was rough with Patient denies any abnormalities
white hairs noted. The scalp was free from any
lesions.

- The contour of the head was round and no

deformities of the suture line noted.

EYES

- Patient’s eyes and eye movements

were “Makakita pa man nuon kog
symmetrical. tarong dong” as verbalized by the
patient.
- Lid margins moist and pink, lashes short, evenly
saced and curled outward; lower margins at the
bottom edge of the iris.

- Round in shape the iris had uniform color.

- No discharges noted.

EARS

- The ears were symmetrical, firm and smooth. Patient denies any abnormalities
Patient did not claim for any pain or tenderness.

- Tympanic membrane was pale gray semitransparent

ovoid cone shape disc. No discharges or

 Page |6

inflammation noted.

-Ears of equal size and similar appearance.

NOSE AND SINUSES

- Patient’s nose was located at the midline of the face

without any deformities. No tenderness or pain was
felt whhen touching it. Patient denies any abnormalities

- Turbinates and middle meatuis visible and same

color as mucosa, moist and free of lessions; septum
symmetrical and uniform without lesions.

- Sinuses both frontal and maxillary were not tender

when palpated.

MOUTH

- No mouth lesions. Complete upper and lower teeth

which were 32. Yellowish color of teeth was noted.
Can move tongue without pain in any direction/ “Nag uga man ni akong ngabil
movement. dong” as verbalized by the
patient.
-The uvula was pink and moist without inflammation
or exudates. Oral mucosa was pink and moist and free
from lesions and unusual odors.

NECK

- Can move neck without any assisstance. Lymph

nodes were not palpable. Patient was able to swallow
without any difficulty. Patient denies any abnormalities

- Dark pigmentations noted.

RESPIRATORY

- Respiration was normal, usually within normal “Di man nuon ko magsige ubo-
range at 18-21 cpm. Lungs were clear to auscultate on ubo” as verbalized by the patient
inspiration and expiration.
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- Respiratory muscles contracts when the patient

inhales and relaxes when patient exhales.

HEART
110
- Heart rate after the delivery was /70 mmHg but
after a day it is still was the same-

Capillary refill time was 1 seconds.

“sa among kaliwat high bloodon
- The pulse was normal that beats 80 beats per man mi pero ako dili man” as
minute. Heart sound was normal which was S1 verbalized by the patient.
follows the long diastolic pause and precedes and
corresponds to each carotid pulsation. S2 follows the
short systolic phase and precedes tha long diastoklic
phase. Patient was regular in rhythm.

BREAST

- Breast was engorged. A slight pain was noted bec of “Nagsakit gamay” as verbalizes
lactation. by the patient.

- Areola was median brown to black, with some small

montgomery tubercles present.

MUSCULOSKELETAL

-Weak movements were noted.

- No discharges on the incision site.

- Muscles strenght was active motion against some “Okey raman wa man koy
resistance that indicates slight weakness. nasinati nga sakit dong” as
verbalized by the patient.
- Muscle tone was passive to stretching.

- Romberg’s test was patient abled to stand straight

with minimal swaying.

ABDOMEN

- Linea negra was visible which was colored dark “Madada ra ang sakit” as
brown and the striae gravidarum recedes to silvery or verbalized by the patient.
white and became smaller
 Page |8

GENITALIA

- Presence of blood in very low amount. No swelling

was noted.

- Lochia rubra (dark red color of discharge) with

small clots was 3.

- Uterus was vissibly outlied unless patient receds to

prepregnant size with exercise.

BLADDER

- Clear yellow color of urine noted and was about 300 “Sige raman ko pangihi dong” as
ml every voiding. verbalized by the patient

NERVOUS

- Patient was conscious, coherent and cooperative. “Dili kaayo sakto akong tulog” as
Mental status was appropriate to her age. verbalized by the patient.

VII. DEVELOPMENTAL DATA

STAGE DEVELOPMENTA INDICATION PATIENTS

L TASK OF POSITIVE BEHAVIOR &
RESOLUTION DEVELOPMENTAL
EXPALNATION
INFANCY Trust vs. Mistrust All needs of the “kahinumdum ko nga
 Page |9

Birth to one year patient were niingon akong mama

provided by the na dili daw ko pabiya,
parents at this mao ana akong mama
stage. Patient was mag sige daw ko
breastfed by her pakugos niya. Dili pa
mother and she daw ko muduol sa lain
also completed the kay muhilak dayun ko.
vaccine. Kung madunggan pud
ko sa ako mama
magdali-dali siya ug
dagan padung nako
bahala mabiyaan iyang
gibuhat”

Infants trust in
familiar and natural
person who are
responsible in its
needs and provide
satisfying experience
as nourishments and
warmth. Through
continuity of
experience with
adults, infants learn to
rely on them and trust
them. When infants
needs which are not
granted immediately
they may develop
mistrust to the parents.

Toddlers Autonomy vs. Shame / Toilet training was “ingnon sa ako mama,
1 – 3 years old doubt emphasized. The dili man daw ko
patient learned to lihukan pagka bata,
walk alone and is kung magdula akong
able to handle mga igsoon,
materials and magtanaw lang daw
wanted to dress ko. Dili daw ko
herself alone. At hingduol ug mga tao.
 P a g e | 10

the age of 3, Unya ingon sad siya

patient is nga kung naa daw koy
successfully toilet makit.an na ilang
trained. pambuhaton,
musunod-sunod kuno
ko nila. Unya ganahan
jud kuno ko nga
masunod akong gusto.
Pero dili man daw siya
maglisod ug badlong
nako kay dali raman
daw ko mu patoo”

A child learns what is

expected of it, what its
obligation and
privileges are and
what limitations are
placed upon it. A
sense of sense control
provides a child with
lasting feelings of
good will and pride.
The child begins to
judge it and others and
to differentiate
between right or
wrong”

Pre-schooler Initiative vs. Guilt The patient went “Ug nahinumduman

3 – 6 years old to school. She as nako ana dong kay
able to gain ganahan jud ko nga
friends. She knew magsunog-sunod sa
when she will be unsa man akong
punished. makit-an. Ingon sa
akong mama nga
magkatawa daw kuno
siya sa ako tungod sa
 P a g e | 11

ako mga pangbuhaton.

Unya ni-ingon pud
siya nako na daghan
kuno kayo ko ug mga
pangutana niya na
wala diri ug wala
didto. Maglisod siya
ug tubag sa uban nako
nga mga pangutauna
kay dili siay kahibalo
unsaon pag tubag ug
pag isplikar.”

The child during this

stage presents itself as
being decisively more
advanced and more
together both
physically and
mentally. The child is
eager to learn well at
this stage, the child
strives to grow in as
sense of obligation
and performance and
in this stage the child
is fond of imitating a
person. A feeling of
guild may hunt the
child over goals
unmet.
School age Industry vs. Inferiority the patient “ni eskwela nako
6 – 12 years old engaged in the anang idara. Kada
activities of the human sa klase kay
school. Began to mu.uli nako dayon kay
gain friends in motabang ko ni mama
school. sa mga buhatonon sa
balay. Dili ko hilig
maglakwatsa ig
kahuman sa klase.
Pangtagaan naman mi
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mga managsoon ug
mga buhatonon na
kinahanglan atumanon
jud kay kasab.an man
pud mi kung dili
matuman. Kadtong
akoa kay ako may
mangling.ag mao sayo
jud ko ma.uli”

The child learns to

have formal education
and develop a sense of
industry and learn the
reward of
perseverance and
diligence, the child
may develop
inferiority if he/she is
unable to master the
task which undertaken
from him/her by
parents and teachers.

Adolescence Identity vs. Role The patient gained “aning edara,

13 – 18 years old confusion identity conscious na kayo ko
And role as a man. sa akong kaugalingon.
she had her Dugay jud kayo ko
puberty. mahuman sa
atubangan sa samin
kay i.sugurado pajud
nako kung gwapa ug
wa naba ga dimao
akong dagway, inig
gawas nako sa among
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balay mag sige lang

jud ko ug kuyug sa
akong mga amiga
manglaag. Malingaw
man gud ko. Unya
kasagaran sa akong
mga amiga kay naa
may uyub. Ako kay
wa ko uyub kay di
pako interisado ato.”

Individual begins to
sense a feeling of
his/her own idea that
he/she is being unique
person and prepared to
fit into some
meaningful role in the
society. They become
aware of his/her likes,
dislikes and have a
strength and purpose
to control his/her
destiny. If the person
is unable to make a
decision, he/she may
feel regressing rather
than progressing and
thus identity confusion
results”
Young adulthood Intimacy vs. Isolation Relationship with “okay ra man ang
19 – 40 years old opposite sex was among pagpuyo karon,
used to be given bisag nagkalisod
importance. kuntento naman ko sa
Patient had a akong bana. Kahebaw
commitment with nako unsaon ug
opposite sex. She pagdala ug pamilya
gave birth to a kay mayo ang
baby boy. pagpadako nako sa
ako mama.
 P a g e | 14

In this stage, young

adults are prepared
and willing to unite
their identity with
others. They seek
relationship intimacy
partnership and
affiliations and are
prepared to develop
the necessary strength
to fulfil his/her
commitments despite
the sacrifices they may
have to make. The
hazard of this stage is
isolation which is the
avoidance of
relationship because
one is unwilling to
commit oneself into.

VIII. ANATOMY AND PHYSIOLOGY AND RELATED PATHOPHYSIOLOGY

A.ANATOMY AND PHYSIOLOGY

FEMALE REPRODUCTIVE SYSTEM

The Human female reproductive system contains two main parts: the vagina and
uterus, which acts as the receptacle for the male’s sperm, and the ovaries, which produce
the female’s ova. All of these parts are always internal; the vagina meets the outside at
the vulva, which also includes the labia, clitoris, and urethra. The vagina is attached to
the uterus through the cervix, while the uterus is attached to the ovaries via the fallopian
tubes. At certain intervals, the ovaries release an ovum, which passes through the
fallopian tube into the uterus.
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If, in this transit, it meets with sperm, the sperm penetrate and merge with the egg,
fertilizing it. The fertilization usually occurs in the oviducts, but can happen in the uterus
itself. The zygote then implants itself in the wall of the uterus, where it begins the
processes of embryogenesis and morphogenesis. When developed enough to survive
outside the womb, the cervix dilates and contractions of the uterus propel the fetus
through the birth canal, which is the vagina.

The ova are larger than sperm and are generally all created by birth. Approximately
every month, a process of oogenesis matures one ovum to be sent down the fallopian tube
attached to its ovary in anticipation of fertilization. If not fertilized, this egg is flushed out
of the system through menstruation. Human pregnancy is somewhat arbitrarily divided
into three trimester periods, as a means to simplify reference to the different stages of
fetal development. The first trimester period carries the highest risk of miscarriage
(natural death of embryo or fetus). During the second trimester the development of the
fetus can start to be monitored and diagnosed. The third trimester marks the beginning of
viability, or the ability of the fetus to survive, with or without medical help, outside of the

Ovaries
The ovaries are the main reproductive organs of a woman. The two ovaries, which are
about the size and shape of almonds, produce female hormones (estrogens and
progesterone) and eggs (ova). All the other female reproductive organs are there to
transport, nurture and otherwise meet the needs of the egg or developing fetus.

The ovaries are held in place by various ligaments which anchor them to the uterus and
the pelvis. The ovary contains ovarian follicles, in which eggs develop. Once a follicle is
 P a g e | 16

mature, it ruptures and the developing egg is ejected from the ovary into the fallopian
tubes. This is called ovulation. Ovulation occurs in the middle of the menstrual cycle and
usually takes place every 28 days or so in a mature female. It takes place from either the
right or left ovary at random.

Cervix

The cervix is the lower, narrow portion of the uterus where it joins with the top end of the
vagina. It is cylindrical or conical in shape and protrudes through the upper anterior
vaginal wall. Approximately half its length is visible; the remainder lies above the vagina
beyond view.

Fallopian tubes

The fallopian tubes are about 10 cm long and begin as funnel-shaped passages next to the
ovary. They have a number of finger-like projections known as fimbriae on the end near
the ovary. When an egg is released by the ovary it is ‘caught’ by one of the fimbriae and
transported along the fallopian tube to the uterus. The egg is moved along the fallopian
tube by the wafting action of cilia — hairy projections on the surfaces of cells at the
entrance of the fallopian tube — and the contractions made by the tube. It takes the egg
about 5 days to reach the uterus and it is on this journey down the fallopian tube that
fertilization may occur if a sperm penetrates and fuses with the egg. The egg, however, is
only usually viable for 24 hours after ovulation, so fertilization usually occurs in the top
one-third of the fallopian tube.

Uterus
the uterus is a hollow cavity about the size of a pear (in women who have never been
pregnant) that exists to house a developing fertilized egg. The main part of the uterus
(which sits in the pelvic cavity) is called the body of the uterus, while the rounded region
above the entrance of the fallopian tubes is the fundus and its narrow outlet, which
protrudes into the vagina, is the cervix.

The thick wall of the uterus is composed of 3 layers. The inner layer is known as the
endometrium. If an egg has been fertilized it will burrow into the endometrium, where it
will stay for the rest of its growth. The uterus will expand during a pregnancy to make
room for the growing fetus. A part of the wall of the fertilized egg, which has burrowed

into the endometrium, develops into the placenta. If an egg has not been fertilized, the
endometrial lining is shed at the end of each menstrual cycle.

The myometrium is the large middle layer of the uterus, which is made up of interlocking
groups of muscle. It plays an important role during the birth of a baby, contracting
rhythmically to move the baby out of the body via the birth canal (vagina).
 P a g e | 17

Vagina
The vagina is a fibromuscular tube that extends from the cervix to the vestibule of the
vulva. The vagina receives the penis and semen during sexual intercourse and also
provides a passageway for menstrual blood flow to leave the body.

B.CONCEPTUAL FRAMEWORK

FEMALE MALE

Process Oocytes produces Sperm cells

Ovulation Sexual Intercourse  mature and move through

the reproductive tract

Menstruation

Sperm cells meets the egg cell in the

ampulla of the fallopian tube

Fertilization happens

Zygote is formed

Zygote becomes a morula

Morula becomes blastocyst

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Blastocyst developed into embryo( until 8 week of gestation)

Embryo then developed into fetus ( until full term)

LABOR

First Stage of Labor occurs

(starts with regular uterine contraction and the end with complete cervical dilation)

Second Stage Of Labor

(from complete cervical dilation to delivery of the baby)

Third Stage of Labor

(starts with childbirth and ends as the placenta is delivered)

Fourth Trimester of Pregnancy ( Puerperium)

(Postpartal period- the 6 week period after birth)

C. DISCUSSION OF PATHOPHYSIOLOGY

Ovulation
 P a g e | 19

In a sexually mature girl, approximately every 28 days an egg cell leaves one of her two
ovaries on its way to the uterus. This is called ovulation. An egg cell is visible without a
microscope: it is about the size of the full stop at the end of this sentence.

Menstruation

When the egg cell is not fertilized it leaves the body about two weeks later along with
cell material on the inside of the womb, which causes a bleeding (menstruation).

Fertilization

If semen is present in the woman’s body shortly before ovulation the sperm cells will
complete to find and penetrate the egg cell. Sperm cells are much smaller than egg cells,
because they can only carry hereditary material, while the egg cell carries nutrition as
well. If the sperm cell were the size of the little boy, the egg cell would be the size of a
house. One ejaculate contains of a hundreds of millions of sperm cells. They have a long
way to go and a lot of them don’t survive the trip through the vagina, the uterus and the
fallopian tubes to the ovaries. The sperm cells that get to the egg (with the help of the
woman’s internal movements) try to penetrate it. One of them succeeds, upon which the
egg become impenetrate to the other sperm cells. This is called ‘fertilization’ or
‘conception’.

Implantation

`Once inside the egg cell, the sperm cell moves to the centre and the 23
chromosomes of the two cells link up, so that the fertilized cell contains the 46
chromosomes typical for humans. Approximately one day later the new cells begin to
divide, while it continues its way till it arrives at the uterus, where, about 6 days after
fertilization, it attaches to the internal surface. In the meantime it has multiplied to several
hundreds of cells.

It is now called embryo. The outside layer of cells from the beginning of the
placenta and navel cord, which serves as a two way channel of transportation for food
and waste.

Embryonic Stage
 P a g e | 20

During the embryonic stage the cells differentiate onto three layers: an outer layer
called ectoderm, which will later form the skin, nails and the nerve system; a middle
layer called mesoderm, which will take care of the skeleton, muscles and blood
circulation; and an inner layer, endoderm, which will develop into lungs, digestive
system and other internal organs. Animal embryos have the same layers. The early stages
of human development show that we are related to other species. For example there is an
egg-like structure around the embryo with a space for yolk (which is the food for birds
while they are still in the egg). Later, the embryo develops a tail and fishlike and gills,
which it then loses again. Throughout the early development, the new life is stress tested.
About 15-20 % of pregnancies end in unnoticed abortions, miscarriage or premature
births, because the embryo is not strong enough to survive. Sometimes the new being has
an adverse effect on the mother, which can lead to sickness and death.

Fetal Stage

During the first two months of pregnancy the main physical functions of the baby are
developed: heart and lungs, skeleton, arms, legs and a relatively large head with the
beginning of eyes and ears. When this groundwork is laid, the embryo is called, “fetus”.
Its size is about 1 inch and it weighs only a few ounces, but its mother probably realizes
that it is on its way.

An important development is the formation of the sex organs. If the sex

chromosome of the fetus is XX, it will develop ovaries, a uterus and a vagina under the
influence of the female estrogen, which is already present in the mother’s body. If the
fetus has an XY chromosome, it will develop a penis and testicles with the help of the
male hormone testosterone, which the mother’s body only produce if the genes on the
XY chromosome tell her to do so.

Male and female sex organs are very similar in the beginning. The penis develops from
the same structure as the clitoris; the testicles from the same structure as the vulva. The
female is obviously the older and primary structure of reproduction.

After 4 months the fetus stretches out, and from then on the mother can fell it kick. After
7 months, or 29 weeks, the fetus has developed a layer of fat under its skin, an it weighs
over 2 lbs. If it were born, it would be premature and very vulnerable, but nowadays
doctor can keep such babies alive with the help of an incubator, oxygen and tube feeding.

The normal duration of pregnancy in humans is about 9 months, or 38 weeks.

When the baby is ready to be born, the mother’s body starts to feel the painful
 P a g e | 21

contractions of her uterus. It takes about 13-14 hrs. for a first child to be born; later
children may take only 7-8 hrs. a full term baby weighs about 6-9 lbs.

Compared with most other animals, a human body is very helpless and needs a
long period of care to develop. We are born early because our heads are so big that they
stretch the vagina to the maximum. After birth, our brain and other organs continue to
grow as if we were still inside. Our long childhood is required for learning to function as
members of a complex society and culture.

D. SYMPTOMATOLOGY

IDEAL ACTUAL
PRESUMPTIVE SIGNS:
 Breast changes  Breast changes
 Nausea  Vomiting
 Vomiting  Frequent urination
 Amenorrhea  Fatigue
 Frequent urination  Linea negra
 Fatigue  Melasma
 Uterine enlargement
 Quickening
 Linea negra
 Melasma
 Striae gravidarum

PROBABLE SIGNS
 Serum laboratory test
 Ballottement
 Chadwick’s sign
 Braxton-hicks contraction
 Goodell’s sign
 Fetal outline felt by the examiner
 Hegar’s sign
 Sonographic evidence of gestational
 P a g e | 22

sac
 Ballottement
 Braxton-hicks contraction
 Fetal outline felt by the examiner

POSITIVE SIGNS OF PREGNANCY

 Demonstration of fetal heart
 Fetal movements  Demonstration of fetal heart

 Visualizations of fetus by  Fetal movements

ultrasound  Visualizations of fetus by

ultrasound

IX. MEDICAL MANAGEMENT

A. TREATMENT AND PROCEDURE

IDEAL
 Post partal management taken
 Intravenous fluid therapy given
 Medications administered
 Monitored vital signs every four
hours
 Intake and output measured and
recorded every shift
 Diet ordered
ACTUAL
 Post partal management taken
 Intravenous fluid therapy given
 Medications administered
 Monitored vital signs every four
hours
 Intake and output measured and
recorded every shift
 diet as tolerated

B. DIAGNOSTIC PROCEDURES

URINALYSIS

TEST NAME RESULT SIGNIFICANCE

MACROSCOPIC
 color Yellow
 P a g e | 23

 appearance SLCLDY
 pH 6.0 Normal

 specific gravity 1.010

 protein (+) High

(-) Low
 glucose

MICROSCOPIC
0-1 Low
 RBC
0-2 Low
 WBC
Few Low
 Epithelial cells
Few Low
 Mucus Threads
Few Low
 Amorphous material
Few Low
 Bacteria

HEMATOLOGY SECTION

TEST NAME RESULTS REFERENCE SIGNIFICANCE

RANGE
WBC 9 k/uL 4.1 – 10.9 Normal
 Segmenters 73.70 k/uL 47.0-80.0 Normal
 Lymphocytes 25.90% 13.0 – 40.0 Normal
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 Monocytes 4.90% 2.0 – 11.0 Normal

 Eosinophils .40% 0.50- 0 Normal

 Basophils 0.10% 0 - 2.0 Normal

RBC 3.90m/uL 4.0 – 5.2 Normal

 Hemoglobin 13 g/dL 12.0 – 16.0 Normal

35.00 L % 36.0 – 46.0 Normal
 Hematocrit
93.00 L fL 80.0 – 100.0 Normal
 MCV
29.10 pg 26.0 – 34.0 Normal
 MCH
30.10 g/dL 31.0 – 36.0 Low
 MCHC
40.40 fL 37.0 – 54.0 Normal
 RDW – SD
13.5 % 11.0 – 16.0 Normal
 RDW – CV
195.00 k/uL 140.0 – 440.0 Normal
 Platelet
10.90 fL 0 – 100.0 Normal
 MDV

X. NURSING MANAGEMENT

A. ACTUAL CARE GIVEN

 Physical assessment done

 Established rapport to the patient and significant others
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 Vital signs taken and recorded every 15 minutes of the first 2 hours and every
hour for four hours.
 Intake and output measured and recorded every 4 hours
 Intravenous fluids checked and regulated
 Due medication given as ordered
- Cefalexin (cefalin) 500mg / ot 3x a day
- Mefenamic acid
- Senokot forte
 Comfort and safety measures provided
 Assess voiding pattern of the patient
 Encouraged patient for adequate rest and sleep
 Monitored patient for any unusualities

B. PROBLEMS ENCOUNTERED DURING THE IMPLEMENTATION OF NURSING

CARE

During the first day of nursing care, the student nurse experience difficulty in
communicating with the patient because the patient was irritable and restless after
delivery. On the following day the student nurse established rapport after encouraging
patient to rest because the patient gave her trust and was cooperative on the procedures
the student nurse performed to her. Patient was also cooperative and seemed lively in
answering questions the student nurse asked her.

C. RESTORATIVE MEASURES USED

The restorative measures used was that the student nurse first established rapport to
patient and significant others then encouraged patient to take adequate sleep and rest,
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assisted the patient in ambulating and in performing activities, provided comfort

measures for patient, and maintained calm and relaxing environment.

D. EVALUATION

After rendering nursing interventions to the patient, the patient was able to attain
adequate sleep and rest, regained strength, was cooperative, was more relaxed and
comfortable and answered all the questions that were asked by the nursing student.

E. PATIENT TEACHING

The student nurse encouraged patient to empty bladder completely, taught patient to
wipe from front to back when cleaning the perineum to prevent infection, instructed the
patient to report to her doctor once she noticed any unusualities, taught and explained the
importance of child and parent bonding, taught the proper breastfeeding techniques, and
explained the importance of breastfeeding.

XI. CONCLUSION AND RECOMMENDATION

Normal spontaneous vaginal delivery is a very common stage in labouring woman.

Thus is managed with a team approach to empower a client to successfully manage this
kind of delivery. As a part of the health team, the nurse plans, organizes and coordinates
care among the various health disciplines involved, also provides care and education,
promotes the clients and the baby health and well being.

The mother as well as the family members should be educated with the different
interventions to manage NSVD clients successfully. During discharged planning, patient
education should be initiated on how toc are properly for the mother and baby.

XII. IMPLICATION OF THE STUDY

A. NURSING EDUCATION
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Studying the concept of normal spontaneous vaginal delivery, helps us to understand

and improve our knowledge towards this kind of delivery. It requires different
appropriate interventions to prevent complications to the mother as well as the baby.
Mothers should be taught how to properly manage their condition by having a regular
prenatal check-up in the course of pregnancy and must be taught how to care for their
babies.

B. NURSING PRACTICE

Through this study, student nurses will be able to gain self-confidence and
determination to add up the skills in rendering care to the patient. Thus, nurses should
render care more effectively and successfully to their clients. Nurses will be able to
identify what type of intervention that must be provided to prevent complication and
infection to mother and the child’s condition and health.

C. NURSING RESEARCH

Through this study, more research will be easy to find and this will serve as reference
with the advent technology, one maybe able to learn and understand fully the said topic.
Nurses should search findings to deliver fully the said care and services to the patient in a
right manner. In that way and in doing so, nurses can deliver care at the utmost best and
optimal level of wellness.

Bibliography:

-Clayton et. At Basic Pharmacology for Nurses – 14th edition Philippines:

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Edition Reprinted 2007.

- Marieb, Elaine N. (2009), Essential of Human Anatomy and Physiology – 9th edition

Jurong, Singapore. Pearson Education Asia Pte. Ltd.

-Weber, Janet et. At. Health Assessment in Nursing – 3rd edition

Copyright by Lippincott Willams and Wilkins Publisher 2007

-Doenges,Marylyn E. Et. At. Nursing Care Plan – 7th edition

Original American edition Publsihed by F.A. Daris Company 2007

-Wong et. At. Maternal and Child Nursing Care – 3rd edition

EL sevier (Singapore) Reprinted Edition 2009