LABOR AND DELIVERY

CASE SCENARIO 3: Belle

Belle came in to the Hospital accompanied by her mother because of labor pain that started 5
hours ago. Cervix is dilated 3cm, 50% effaced. Membranes is intact. Fetal Heart Tone is 140
beats per minute. Fetus is in cephalic presentation as revealed in ultrasound. Uterine
contraction is moderate to strong in intensity with duration of 45 seconds and with an interval
of 3 minutes. Upon assessment bladder is distended. She was encouraged to void. Place on
NPO while in active labor. IVF of D5LR 1L. to run at 30gtts/min..

 Belle presented her laboratories results as follows:

1. CBC
A. Hgb   __________ 142g/L
B. Hct   __________ 0.41 Vol. Fr
C. RBC   __________ 4.41 x 10ͮ^12/L
D. WBC  __________ 6.4 x 10^g/L

2. Urinalysis-

 Physical Properties
Color Straw
Transparency Hazy
Reaction 5.0 (acidity)
Specific Gravity 1.025
Chemical Tests
Sugar Negative
Albumin Negative
Microscopic Findings
Pus Cells Occasional 0-3
RBC Occasional 2-4
 

Vital Signs revealed as follows;

Temperature 37.1°C
Pulse Rate   88 bpm
Respiratory Rate 20 cpm
Blood Pressure 130/80 mmHg
FHB 140 bpm

Belle hold her abdomen, screams and shout, “Why does this hurt so badly”, I wish my boyfriend
is here.

After 3-4 hours from admission Belle complains of increased uterine contractions.With intensity
occurring every 2-3 min. and with a duration of 60-70sec. Bloody show and rupture of the
membranes noted. Internal examination done revealed 10 cm. cervical dilatation.

Belle transferred to delivery room per stretcher. She complaints the urge of bearing down.
After an hour she delivered to an alive baby girl via NSVD.
Questions:

1. Interpret the vaginal examination done to Belle when she came in the lying-in clinic based on
the record presented in the scenario (3cm, 50%effaced).
Belle is in the early stages of labor, based on the results. This stage lasts three to five hours and
lasts from the time your cervix is 3 cm to the time it is 7 cm dilated. It happens when you start
having regular contractions. The cervix opens and softens, shortens and thins as a result. This
makes it possible for the infant to enter the delivery canal. Because this is Belle's first labor, the
cervix may take some time to fully efface. The cervix thins and then dilates, labor may start
slowly. The Contractions will last about 30-45 seconds, giving belle 5-30 minutes of rest between
contractions. The Contractions are typically mild and somewhat irregular but become
progressively stronger and more frequent as it goes on. Belle can spend this time at home or
wherever you're most comfortable.

2. Ultrasound of Belle revealed cephalic presentation. Explain cephalic presentation?

A cephalic presentation, also known as a head presentation or head-first presentation, occurs
when the fetus is in a longitudinal position and the head enters the pelvis first during birthing.
The baby should be placed head-down, facing your back, with its chin tucked to its chest and the
rear of its head ready to enter the pelvis during labor. Most babies settle into this position with
the 32nd and 36th week of pregnancy. You’ll know if the baby is in cephalic position when you
can feel their bottom or legs above your belly button. The vertex presentation, in which the
occiput is the leading section, is the most common type of cephalic presentation. All other
presentations are aberrant, making them more difficult to deliver or impossible to deliver
naturally. If you're getting closer to your exciting due date, you might have heard your doctor or
midwife mention the term cephalic position or cephalic presentation. This is the medical way of
saying that baby is bottom and feet up with their head down near the exit, or birth canal.
Factors that influence this positioning include the gestational age, size of the head,
malformations, amount of amniotic fluid, presence of multiple gestations, presence of tumors,
and others. By about 32 weeks, the baby is usually lying with their head pointing downwards,
ready for birth.

3. Belle’s duration of uterine contraction lasted 45 seconds with an interval of 3 minutes. Discuss
the stages and phases of labor she experienced.
The initial stage of labor is the most time-consuming, lasting up to 20 hours. It starts when your
cervix begins to open (dilate) and concludes when it is entirely open (fully dilated) at a diameter
of 10 centimeters. When labor starts, it is called the early or latent phase. Mild contractions will
occur every 15 to 20 minutes and last 60 to 90 seconds. The frequency of your contractions will
increase until they are fewer than 5 minutes apart. When Belle arrives, her cervix dilates from 6
to 8, her contractions become harder, and she is in the active phase, which lasts around 3
minutes and 45 seconds. She could be experiencing back pain and vaginal bleeding. The
contractions may get more stronger if your amniotic membrane ruptures or your "water bursts"
at this time. When your cervix is fully dilated to 10 centimeters, you enter the second stage of
labor. This period lasts until your baby is born, after passing via the birth canal and vagina. It's
possible that this stage will take up to two hours. The third stage of labor occurs after the baby
is born and ends when the placenta separates from the uterine wall and is passed via the vagina.
This is also known as "afterbirth delivery" because it is the shortest stage of labor. It could last
anywhere from a few minutes to a couple of hours. There will be contractions, but they will be
less uncomfortable. If you have an episiotomy or a little rip at this stage of labor, it will be
stitched.

4. Why do we advise the mother on NPO during labor?

Childbirth requires your participation. It's rare to receive general anesthesia during vaginal
delivery because it makes you unconscious. In the 1940s and 1950s, many Western countries
implemented nothing by mouth (NPO) policies in labor wards in the hopes of reducing the
incidence of pulmonary aspiration of gastric contents in the event that general anesthesia was
required. The risk of aspiration was higher in pregnant women who were put under general
anaesthetic. When food or liquid is inhaled into the lungs, it is known as aspiration. The main
reason that some hospitals have a “Nothing by Mouth” policy is to ensure that laboring people
 have an empty stomach should they need emergency surgery with general anesthesia. Stomach
emptying slows down once labor starts, so fasting for 8, 12, or even 24 hours after contractions
begin may not guarantee an empty stomach at the time of birth. Women who will undergo
elective cesarean birth are advised to fast from solids for 6 to 8 hours. Current evidence
suggests that solids and semi-solids should be avoided once a woman is in active labor or
requests analgesia. he appropriate advice is to allow a carefully audited introduction of isotonic
drinks.

5. FHR was checked and revealed 140 beats per minute. What is a normal fetal heart rate during
labor? During childbirth, a baby's heart rate should be between 110 and 160 beats per minute. It
may fluctuate above or below this rate for a variety of reasons. Short bursts of acceleration of
the baby's heart rate are common and indicate that the baby is getting an adequate oxygen
supply. We define fetal distress as a deceleration of the fetal heart rate to 60 bpm for >2
minutes. Heart rate increases when baby moves. Heart rate increases during contractions. Heart
rate returns to normal after baby moves or after a contraction. Typically, an abnormally fast
heart rate is over 200 beats per minute. This is not a problem for most babies. But the heart rate
of some babies gets slower. This change in heart rate can be seen on the external fetal monitor.

6. Ms. Belle presented her laboratories. What is the normal reference value? Discuss the
significance if it is elevated and decreased result during pregnancy.
Belles urine is hazy, indicating dehydration, which occurs when you lose more water than you
take in. Dehydration is a common cause of dark, murky urine. Due to specific situations,
excessive protein or crystalline particles in the urine may cause it to appear cloudy or foamy
over time. Acidity is natural since the lower the pH, the more acidity, and the higher the pH, the
less acidity. In the chemical test, sugar and albumin are both negative, indicating that everything
is fine. Pus cells are occasionally 0-3 on microscopic examination, which is abnormal because a
pregnant woman's pus cells should be 0-5 on average. The urine may appear cloudy or as if it
contains pus if you have pyuria. Your RBC level may be 2-4, which is normal. The rest is routine.
Belles need to rest. Hydrating herself was also a must.
7.  State and discuss psychological behaviour presented in the scenario as verbalized by Ms. Belle.
Miss Belle is becoming increasingly concerned as her due date approaches, but her companion
has yet to appear. She must have felt isolated and in need of assistance much more now. This is
understandable, especially as she approaches the end of her pregnancy and need someone to
accompany her from the beginning to the end. She is becoming irritated with the current
circumstances, which is a common symptom of psychological changes throughout pregnancy's
third trimester. Some women experience a decrease in their symptoms during pregnancy.
Hormonal changes during pregnancy were affecting the chemicals in the brain. This causes
anxiety that made Belle anxious. It will have an adverse effect on mother and baby. Some
actions that must be taken are taking enough sleep and staying active. Belle must also schedule
her time in a day to relax.

8. Identify and discuss the stage of labor in the progress of uterine contractions of Ms Belle
presented in the case scenario.
There are two stages of uterine contractions: early and latent phase. When the cervix begins to
change to allow the baby to pass through while contractions are modest. The active phase was
longer in induced labors than in labors with spontaneous onset in nulliparous women. When
contractions are intense and most of the work is done to prepare your body for birth, you are in
the active phase. Transitional phase is a period of transition when you begin to feel the need to
push. Belle is in the active phase, as she is said to be having contractions of moderate to high
intensity. During active phase the cervix will dilate from 6 to 10 centimeters. The contractions
will become stronger, closer together and regular. The legs might cramp, and you might feel
nauseated. The pregnant might also feel that the water will break and experience increasing
 pressure in the back.

9. As crowning occur, is episiotomy applicable to Ms. Belle? Why?

An episiotomy widens the aperture of the vaginal canal, making it easier for the infant to pass
through. It is an incision through the area between your vaginal opening and your anus. This
area is called the perineum. An episiotomy was thought to help prevent more extensive vaginal
tears during childbirth and heal better than a natural tear. This surgery is performed to increase
the size of your vaginal opening in preparation for childbirth. After having an episiotomy, it is
normal to feel pain or soreness for 2-3 weeks after giving birth. It was recommended to perform
episiotomy before crowning. Normal delivery is possible without episiotomy. Infection is
possible when episiotomy is being done. Forceps delivery, FHR concerns, ventouse delivery,
vaginal breech, face to pubes, previous history (H/O) of perineal tear, maternal tiredness, and
inflexible perineum were all reasons for episiotomy. Episiotomy isn't an option for Belle because
she's had the NSVD.

10. What is Ritgen Maneuver? Explain the indication in performing Ritgen Maneuver?
Crowning is the word used to describe when the fetal head forcibly extends the vaginal outlet. A
Ritgen maneuver can be performed to deliver the head. The Ritgen technique is an obstetric
method that midwives and doctors employ to control fetal head delivery. It means that the fetal
chin is reached for between the anus and the coccyx and pulled anteriorly. Ritgen Maneuver
was used to control speed of delivery. To protect the perineum, Ritgen advocated withdrawing
the fetal head using this method in between uterine contractions. In the 1950s and 1960s, the
rate of intact perineum in vaginal deliveries without episiotomy ranged from 96.2 percent to
100 percent, with a drop to 46 percent in 2010. The study revealed the modification of Ritgen
maneuver described to have resulted in significant reduction of all grades of perineal tear over
decades. The use of the Ritgen´s maneuver decreases the risk of anal sphincter injury at
delivery, compared with simple manual protection of the perineum. It is not protective for
severe perineal lacerations and is associated with higher post-partum pain.

11. Enumerate and briefly discuss the 2 types of episiotomy

*Midline Episiotomy
An incision is performed in the Centre of the vaginal entrance, straight down toward the
anus, in a midline episiotomy.
Easy repair and faster healing are two advantages of a midline episiotomy. This sort of
episiotomy is also less painful, and it is less likely to cause long-term soreness or pain problems
during sexual activity. A midline episiotomy is also associated with decreased blood loss.
A midline episiotomy's main disadvantage is the increased possibility of rips extending
into or through the anal muscles. Long-term consequences of this type of injury include fecal
incontinence, or the inability to control bowel motions.

*Mediolateral Episiotomy
In a mediolateral episiotomy, the incision starts in the middle of the vaginal entrance
and extends at a 45-degree angle down to the buttocks.
The main benefit of a mediolateral episiotomy is that the danger of anal muscle rips is
significantly reduced. However, there are numerous drawbacks to this type of episiotomy,
including more blood loss, more extreme pain, more difficult repair, and a higher chance of long-
term discomfort, particularly during sexual activity.

12. Explain are the mechanisms of labor?

*Engagement - Your engagement indicates to your doctor that your pelvis is large enough for
the baby's head to move down (descend). The broadest part of your baby's head has entered
the pelvis at this point.
* Descent - The uterine fundus exerts pressure on the fetus, causing descent. The woman will
feel the normal "pushing feeling" that occurs throughout labor when the fetal head presses on
the sacral nerves as well as the pelvic floor. This is when your baby's head descends farther into
 your pelvis. Descent usually happens during labor, either as the cervix dilates or after you start
pushing.
* Flexion - The baby's head is flexed down such that the chin meets the chest during descent. It
is easier for the baby's head to pass through the pelvis with the chin tucked. When the fetal
head reaches the pelvic floor, the head bends forward on the chest, allowing the smallest
anteroposterior diameter to enter the birth canal.
* Internal Rotation - This action positions the shoulders, which will follow, in the best position to
enter the inlet, or aligns the shoulders' widest diameter (a transverse one) with the inlet's wide
transverse diameter. Usually, the baby will be face down toward your spine. Sometimes, the
baby will rotate so it faces up toward the pubic bone.
* Extension - The rear of the neck ends beneath the public arch as the occiput of the fetal head
is born, acting as a pivot for the remainder of the head. The top of the head, the face, and the
chin are born as the head grows.
* External Rotation - The infant's head rotates a last time very immediately after birth, returning
to the diagonal or transverse position during the early portion of labor. This positions the after-
coming shoulders anteroposteriorly, which is ideal for entering the outlet. The anterior shoulder
is born first, maybe due to the infant's head flexing downward.
* Expulsion - Because of the lower size of the infant, the rest of the baby is born effortlessly and
smoothly once the shoulders are born. The pelvic division of labor comes to an end with this
shift. After the shoulder, the rest of the body is usually delivered without a problem.

13. Enumerate and explain the signs of placental separation.

The placenta separates from the uterus during pregnancy, causing placental abruption. Bleeding
and stomach pain are common symptoms, especially in the third trimester. Placental abruption
symptoms vary from person to person. During the third trimester of pregnancy, the most
common symptom is vaginal bleeding with cramping. Abdominal pain, uterine contractions that
are longer and more severe than normal labor contractions, uterine soreness, backache or back
pain, decreased fetal activity, and vaginal bleeding are all possible symptoms or indicators.
Because the blood is contained between the placenta and the uterine wall, there may be no
apparent bleeding in some cases. Pain can range from moderate cramping to intense
contractions, and it usually appears out of nowhere. It's critical to get care for a probable
placental abruption as soon as possible. According to the American Pregnancy Association, fetal
death occurs in 15% of severe placental abruption instances. Placental abruption is a pregnancy
problem for which no cause has been identified.
 14. Formulate a nursing care plan base on Ms. Belle

DEFINING NURSING OUTCOME, NURSING RATIONALE EVALUATION

CHARACTERISTICS DIAGNOSI IDENTIFICATION/OBJECTIV INTERVENTION
S E
SUBJECTIVE: Labor pain LONG TERM: INDEPENDENT:
may be related
Belle holds her to increased Establish a rapport Answers to met
abdomen, screams uterine that enables the questions can
and shouts, “Why contractions as client/partner to feel alleviate fear
does this hurst so evidence by comfortable asking and promote
badly” the clients’ questions. understanding.
verbalizations
of “Why does Discuss anticipated Helps prepare met
this hurt so changes/differences in client because
badly” labor pattern and induction
contractions. procedures
OBJECTIVE: and use of
SHORT TERM: oxytocin can
T: 37.1 °C RATIONALE: After an hour of nursing result in rapid
PR: 88 bpm intervention the client will onset of
RR: 20 cpm Labor pain report pain is strong,
BP: 130/80 mmHG occurs due to reduced/manageable and frequent
FHB: 140 bpm contractions of will appear relaxed contractions,
Cervical dilation: 10 the muscles of between contractions. which often
cm the uterus and interfere
by pressure on negatively
the cervix. with the
client’s ability
to use learned
NOTE: coping
Nursing techniques,
Diagnosis which a slower
should be build up in the
based on the contractile
(NANDA pattern would
Approved allow.
Nursing
Diagnosis) Massage – have her to help ease met
folks massage your the mother
back or feet. and manage
Breathing – deep, slow her labor pains
breaths and grunting
are two examples of
the many different
ways to breathe
through the pain of
contraction.
Visualization- You may
find it helpful to
picture yourself
somewhere enjoyable
such as on a beach or
walking through a
forest.
Water – soak in a tub
or take a shower to
soothe some tension.

Review/provide Encourages met

instruction in simple relaxation and
breathing techniques. gives client a
means of
coping with
and controlling
the level of
discomfort.

Encourage and assist Prevents/limit met

the client with change s muscle
of position, and fatigue;
readjust EFM. enhances
circulation

Encourage clients to Relaxation can met

use relaxation aid in reducing
techniques. Provide tension and
instructions as fear, which
necessary. magnify pain
and hamper
labor progress.

Provide comfort Promotes

measures (e.g., relaxation,
effleurage, back rub, reduces
propping with pillows, tension and
applying cool anxiety and
washcloths, offering enhances
ice chips/lip balm). clients coping
and sense of
control.

Administer analgesic Relieves pain;

medications once promotes
dilation and relaxation and
contractions are coping with
established. contractions,
allowing
clients to
remain
focused on
work or labor.

COLLABORATIVE:

laboratories results as
follows:
CBC
 - HGB: 142g/L
- Hct: 0.41 Vol.Fr
- RBC: 4.41 X 10ꙟ12/L
- WBC: 6.4 X 10ꙟg/L

URINALYSIS
Physical Properties
- Color: Straw
- Transparency: Hazy
- Reaction: 5.0
(acidity)
- Specific Gravity:
1.025

Chemical Tests
- Sugar: Negative
- Albumin : Negative
Microscopic Findings:
- Pus Cells:
Occasional 0-3
- RBC: Occasional 2-4

15. Base on this finding formulate 2 nursing diagnosis

(a) Labor pain related to increased uterine contractions as evidenced by the client’s by the
client’s verbalization of “why does it hurt so badly.”

(b) Perineal pressure related to urge of bearing down as evidenced by cervical dilatation.