Case: 
Read and analyze the given History of past illnesses:
case to do the following activities and
answer questions correctly.
 
A WOMAN IN LABOR
Sally Hudson is a 28-year-old  resident
of Brgy. Tibanga, Iligan City, G1P0,
married, her religion is roman catholic,
41 weeks pregnant woman admitted to
your maternity service at Tibanga
General Hospital, in labor.
 Chief concern:
 “I’m in labor. Tell me what I’m
supposed to do.”
History of chief concern:
 Sally was admitted at 05:00 AM
on 19 September 2020.
Membranes ruptured at 04.00.
Contractions are 2 in 10, lasting
25 seconds. She last ate or drank
8 hours ago.
Family profile:
 She is separated from the father
of the baby for 7 months. Her
close female friend is with her to
be a support person in labor. The
client works as French teacher at
a state university; she is taking
courses part-time toward her
doctorate. She lives in a one-
bedroom condo by herself. She
has supplies prepared for her
infant.
 She had chickenpox at age 3
years. She had dislocated
kneecap at age 14 years and
again at age 16 years. She had no
major illnesses and no
hospitalizations.
History of family illnesses:
 Her grandmother has Alzheimer’s
disease. Father died of Ischemic
stroke. A sister had rheumatic
fever as a child.
Gynecologic history:
 Menarche was at age 11 years;
duration of cycle is 32 days.
Length of menstrual flow is 7
days. She was treated for
trichomoniasis twice last year.
She had no other STIs. Last
Menstrual Period was December
21, 2019.
Obstetric history:
 She had no previous pregnancies.
This pregnancy was not intended
but is wanted. She had prenatal
care with a private obstetrician
since the second month; she was
found to be anemic early in
pregnancy and was treated with
an extra iron supplement. She
attended preparation for labor
classes with a friend as coach.
Day history:
 Nutrition: 24-hour recall
nutritional history reveals
adequate pregnancy diet; took
prenatal vitamin and extra iron
 supplement routinely; last ate
toast and coffee 8 hours ago.
 Sleep: Sleeps 6 hours per night;
one afternoon nap
 Recreation: Has participated in
aerobics class for pregnant
women during pregnancy; had
an exercise program of daily
jogging before pregnancy
Review of systems:
Neuropsychologic: Had febrile
convulsions two times as preschooler;
maintained on phenobarbital until she
was 6; no further difficulty
General appearance: Composed, well-
groomed, young adult pregnant
appearing woman breathing without
apparent distress with           
contractions; height: 5 ft 5 in.; weight:
142 lb; temperature: 37°C; BP: 112/70
mmHg
HEENT: Normocephalic; nose: no
discharge present; mucous membrane
pale red; throat: pink in color and is
smooth and consistent in texture; pink
tongue with visible papillae;  ears: no
inflammation with presence of
yellowish-brown earwax
Chest: Breasts full and soft; no masses
palpable; lungs: no abnormal lung
sounds upon auscultation;
respiratory rate: 20 breaths/min; heart
rate: 70 beats/min, no murmur
Abdomen: Fundal height at 35 cm; fetus
palpable in ROA position; linea nigra and
striae  present: FHR: 150 beats/min
Pelvic examination: Cervix is 2 cm
dilated; the fetal head is 4/5 palpable
above the symphysis pubis
Extremities: Negative
 
Sally is in labor. She is further
admitted for labor management and
admitted with the following orders:
IVF: D5LR @ 20 gtts/min
Diet: DAT
Diagnostics: CBC, BT, HBSag
Drug: 10 units Oxytocin/ 1L D5LR @20
gtts/min
During labor monitoring, the following
are observed:
13.00 (8 hours later). The fetal head is
3/5 palpable above the symphysis pubis.
The cervix is 5 cm dilated. Sally is now in
the active phase of labor.
➢          3 contractions in 10 minutes,
each lasting 40 seconds
➢          Fetal heart rate (FHR) 120
➢          Membranes ruptured, amniotic
fluid clear on pad check
➢          Sutures of the skull bones are
apposed (molding +), no caput
➢          Blood pressure 120/70 mmHg
➢          Temperature 36.8°C
➢          Pulse 80/minute
➢          Urine output 200 mL; negative ➢                Blood pressure 100/70
protein and acetone mmHg

➢                Urine output 150 mL;

negative protein and acetone
Over the next four hours, the following
were observed:  

09.30    FHR 120, Contractions 2/10 each
30 seconds, Pulse 80/minute
10.00    FHR 136, Contractions 2/10 each
30 seconds, Pulse 80/minute
10.30    FHR 140, Contractions 2/10 each
35 seconds, Pulse 88/minute
11.00    FHR 130, Contractions 2/10 each
40 seconds, Pulse 88/minute,
Temperature 37°C
17.00 Vaginal assessment shows that the
cervix is now fully dilated and the head
has descended to 0/5; Sally now feels
expulsive.
17.20: Spontaneous birth of a live female
infant weighing 2,850 g
17:25: Oxytocin 1 amp given IM at
patient’s R deltoid
17:30: Placenta out, BP: 120/80mmHg

11.30    FHR 136, Contractions 3/10 each Latest V/s as follows:

40 seconds, Pulse 84/minute, Head is 2/5 T: 37.4, P: 100 bpm, BP: 120/80mmh, R:
palpable 21cpm, 02 sat: 98%

12.00    FHR 140, Contractions 3/10 each

40 seconds, Pulse 88/minute

12.30    FHR 130, Contractions 3/10 each

45 seconds, Pulse 88/minute

13.0      FHR 140, Contractions 3/10 each

45 seconds, Pulse 90/minute,
Temperature 37°C

           Other observations during this

time: The fetal head is 2/5 palpable
above the symphysis pubis

➢                The cervix is 5 cm dilated

➢                Amniotic fluid is clear

➢                Sutures apposed