BSN2 OB ward/ Delivery Room

SCENARIO 1

UNANG HILAB NI MARIA

Maria is a 27-year-old married, bank employee, few hours prior to admission on

February 7, 2021, Maria complained of moderate lumbosacral pain. She was rushed by
her husband to Grego Hospital. Upon arrival to the Emergency room at 9:20pm, she
was assessed with globularly enlarged abdomen and a 4-5cm cervical dilatation
examined by Dr. Jam B., Fetal heart rate of 135bpm. Dextrose 5 percent LRS (Lactated
Ringers Solution) 1 liter for 41-42 gtts/min and NPO(Nothing per orem) was instructed,
with previous laboratory result attached to the chart (CBC (Complete Blood Count) ,
Blood typing, HBSAg (Hepatitis B Surface Antigen), U/A (Urinalysis), UTZ (Ultrasound)).
After all the assessment in ER (Emergency Room), she was transferred at the Delivery
room per stretcher. Patient Maria had an on and off moderate uterine contraction. After
an hour she was placed on the DR(Delivery Room) table, perineal preparation and
draping done.
At 11:10pm she gave birth to an alive baby girl via Normal Spontaneous Delivery
followed by expulsion of the placenta at 11:20pm. BP was taken and revealed
100/80mmHg (Milliliters per mercury). 1 ampule of Methyl Ergometrine Maleate was
given via IV push as stat dose. Episiorraphy was done under local anesthesia at
11:45pm.
Patient transferred at the Obygine ward down with the latest BP of 100/80 mmHg;
patient is conscious and coherent; with slight vaginal bleeding and well contracted
uterus.

TASK:

1. Anatomy and Physiology of the female reproductive system.

ANATOMY AND PHYSIOLOGY OF FEMALE REPRODUCTIVE SYSTEM

Internal
VAGINA
-passageway for elimination of the menstrual flow; it receives the
penis during sexual intercourse; and it forms the lower portion of the
birth canal.

CERVIX
- the narrow neck at the upper end of the vagina.

FUNDUS
-is a narrow tube continuous with the isthmus, and it leads through the
thick uterine wall to the uterine cavity, where fertilized eggs normally
attach and develop.

UTERINE TUBE
-to transport sperm toward the egg, which is released by the ovary,
and to then allow passage of the fertilized egg back to the uterus for
implantation.

FIMBRIAE
-also known as fimbriae tubae, are small, fingerlike projections at the
end of the fallopian tubes, through which eggs move from the ovaries
to the uterus.
ENDOMETRIUM
-playing key roles during the menstrual cycle as well as during
pregnancy. Also called the endometrial lining, the tissue it's made up of
serves as the "wallpaper" of the uterus.

MYOMETRIUM
-the middle layer of the uterine wall, consisting mainly of uterine
smooth muscle cells (also called uterine myocytes) but also of
supporting stromal and vascular tissue. Its main function is to induce
uterine contractions.

OVARY
-the ovaries are small, oval-shaped glands that are located on either
side of the uterus.

FALLOPIAN TUBE
- these are narrow tubes that are attached to the upper part of the
uterus and serve as pathways for the ova (egg cells) to travel from the
ovaries to the uterus.
UTERUS
-hollow, pear-shaped organ that is the home to a developing fetus. The
uterus is divided into two parts: the cervix, which is the lower part that
opens into the vagina, and the main body of the uterus, called the
corpus.
URETHRA
- tube allows urine to pass outside the body. The brain signals the
bladder muscles to tighten, which squeezes urine out of the bladder.

OTHER TERMINOLOGIES

BARTHOLIN'S GLANDS
-the Bartholin's glands also known as the greater vestibular glands
(homologous to the bulbourethral glands in males) are two pea-sized
glands located slightly lateral and posterior to the vagina opening.
These two glands function to secrete a mucus-like substance into the
vagina and within the borders of the labia minora. This mucus
functions as a lubricant to decrease friction during intercourse and a
moisturizer for the vulva.

SKENE'S GLANDS
-the Skene's glands, which are also known as the lesser vestibular
glands (homologous to the prostate glands in males), are two glands
located on either side of the urethra. These glands are believed to
secrete a substance to lubricate the urethra opening. This substance is
also believed to act as an antimicrobial. This antimicrobial is used to
prevent urinary tract infections. The function of Skene's gland is not
fully understood but is believed to be the source of female ejaculation
during sexual arousal.

PERINEAL
-(also called the perineum) is the space between the vaginal opening
and your anus. During a typical vaginal delivery, the skin of your
vagina prepares for childbirth by thinning out. This part of your body is
meant to stretch and allow the baby's head and body to pass through
without trauma

LUMBOSACRAL
- site of most movements of the lumbar spine. The movements occurring
in this joint are mostly flexion and extension, and a minimal degree of
lateral flexion. The degree of motion in the lumbosacral joint varies
depending on age and individual characteristics.

DILATATION
- that the cervix opens. As labor nears, the cervix may start to thin or
stretch (efface) and open (dilate). This prepares the cervix for the baby
 to pass through the birth canal (vagina). How fast the cervix thins and
opens varies for each woman.

UTERINE CONSTRACTION
- periodic tightening and relaxing of the uterine muscle, the largest
muscle in a woman's body. Something triggers the pituitary gland to
release a hormone called oxytocin that stimulates the uterine
tightening. It is difficult to predict when true labor contractions will
begin.

*In learning about pregnancy and delivery, understanding the anatomical

structures involved in production of eggs (ova), fertilisation and fetal
development is fundamental. In this section, you will learn how to identify
and describe the internal female reproductive organs involved in these
processes. Knowledge of the position and function of these organs is also
essential for the accurate examination of pregnant women, and a safe labour
and delivery.

EXTERNAL

MONS PUBIS
-Is rounded, soft fullness of subcutaneous fatty tissue,
prominence over the symphysis pubis that forms the anterior border of
the external reproductive organs.
- It is covered with varying amounts of pubic hair.
LABIA MAJORA
-The labia Majora are two rounded, fleshy folds of tissue that extended
from the mons pubis to the perineum.
-It is protect the labia minora, urinary meatus and vaginal introitus.

LABIA MINORA
-It is located between the labia majora, are narrow. The lateral and
anterior aspects are usually pigmented. The inner surfaces are similar
to vaginal mucosa, pink and mois. Their rich vascularity.

CLITORIS.
- highly sensitive to temperature, touch, and pressure sensation. Site
of sexual arousal.

PREPUCE
- upper junction of the labia

FOURCHETTE
- Lower junction of the labia

VESTIBULE
- Almond shape organ that holds other structure

*URETHRAL OPENING – skenes gland “Paraurethral” , UPPER

*VAGINAL OPENING- Bartholins Gland ‘Paravaginal’ , LOWER
*All the structures which are visible externally, surrounding the urethral and vaginal
openings, including the mons pubis, labia majora, labia minora, vestibule and perineum,
make the external female genitalia. Sometimes these structures are collectively named
the vulva.
*The external female genitalia (or vulva). Structures in the external female genitalia
have a nerve supply, which can respond to different sensory stimuli (touch, pain,
pressure and temperature). This makes these structures sensitive and active to sexual
arousal during touch, especially by the male partner. Following this, the sexual act
between the male and female facilitates the ejaculation of male sex cells into the
female internal reproductive organs, initiating the process of fertilisation, pregnancy,
labour and delivery.

*Knowing about the anatomical position of all these structures is very important during
pregnancy, labour and delivery. Pregnant woman, the enlarging uterus containing the
growing fetus will push down on the bladder and large intestine. This can often result in
decreased urine-carrying capacity of the bladder, so the woman has to urinate (pee)
more frequently, and she may also experience constipation (drying and difficulty of
passing stools).
2. Give at least 2 priority nursing care plan (NCP) to this patient.

Assessme Diagnosi Plannin Implementati Rational Evaluatio

nt s g on e n
Subjective:
Chief complain > Pain > After 3 > Provide and > It > After 3
of lumbosacral related to hours of encourage the use of promotes hours of
uterine rendering comfort measures relaxation, rendering
Objective: contractions nursing such as massage which nursing
 4-5 cm as interventio enhance the intervention,
cervical evidenced n, client feeling of a the client has
dilation by the will engage well-being reported that
patient’s into pain and may pain is
complain of measures reduce the reduced into
lumbosacral to reduce need for manageable
pain. the pain/ analgesia. level.
discomfort
during > Coach the use of Goal met.
labor breathing/ relaxation > It gives -
technique and client a
abdominal effleurage means of Patient will
coping and verbalize
controlling understandin
the level of g of what is
> Encourage, discomfort. happening.
provide information -
about labor progress > Providing
and give positive emotional Patient will
feedback for client’s support can identify/use
efforts reduce fear effective
and coping
> Record the minimize techniques.
frequency, intensity pain
and duration of
uterine contractile > The
pattern per protocol. informations
are
necessary
for choosing
appropriate
intervention
s and to
> Have medications prevent
ready like pain undesired
relievers side effects
 of
> Identify source, medication.
location, and extent
of discomfort; note > For pain
signs and symptoms relief
of infectious process. medications

>Provide information
about hygienic > To
measures such as determine
frequent bathing, the course
use of cotton of treatment
underwear, and and
application of individual
cornstarch for client intervention
with vaginal s.
discharge associated -
with STDs
(chlamydial infection Helps
or gonorrhea). promote
dryness and
> Encourage prevent skin
increasing oral fluid breakdown.
intake and voiding in -
warm sitz bath for
client with Urinary Helps
tract infection. prevent
stasis;
warmth
relaxes
perineum
and urinary
meatus to
facilitate
voiding.

3. Discuss the therapeutic effect, side effect and your nursing responsibilities in
administering the medicines given to Maria.
4. Enumerate the roles and responsibilities of a nurse in assisting patient with
abdominal contractions in Normal Spontaneous Delivery.

• Assessing the needs of the women in labour.

Every woman needs a different kind of support. But all women need kindness, respect
and attention. Watch and listen to her to see how she is feeling. Encourage her, so she
can feel strong and confident in labour.

• Help the patient in labour to relax

Help her relax and welcome her labour. When you support the mother’s labour, you
help her relax instead of fighting against it.  Although labour support will not make
labour painless, it can make labour easier, shorter and safer. You will learn many ways
to support the labour in this study session, including by physical actions (touch, sounds,
etc.) and giving psychological and emotional support.

Encourage the patient to empty her bladder at least every 2 hours.

To check if the bladder is full, feel the mother’s lower belly. A full bladder feels like a
plastic bag full of water. When the bladder is very full, you can see the shape of it under
the mother’s skin. f the mother’s bladder is full, she must urinate. If she cannot walk, try
putting a pan or extra padding under her bottom and let her urinate where she is. It may
help her to begin to urinate if you dip her hand in warm water.

Monitoring the time of contractions during labor and delivery

- = Because this is necessary to accurately differentiate between several

common pregnancy complication, such as prolonged labor and
obstructed labor

• Encourage the patient to try different breathing throughout the labour: such as slow
blowing, hee breathing, panting and strong blowing.

The way a woman breathes can have a strong effect on how her labour will feel. In the
first stage of labour, there are many kinds of breathing that may make labour easier. Try
these ways of breathing yourself and show the mother how to do it. Help her to choose
which one works best to minimise the pain. Encourage mothers to try different ways of
breathing throughout labour:

 Slow blowing. Ask the woman to take a long, slow breath. To breathe out she
should make a kiss with her lips and slowly blow. Breathing in through the nose
can help her breathe slowly.

 Hee breathing. The woman takes a slow deep breath and then blows out short,
quick breaths while she makes soft ‘hee, hee’ sounds.

 Panting. The woman takes quick, shallow breaths.

 Strong blowing. The woman blows hard and fast.

• Keep her informed about the progress of her labour, so she remains relaxed and confident

• Monitor maternal condition by measuring her blood pressure and temperature

every 4 hours, and her pulse rate every 30 minutes.

f her diastolic blood pressure (the bottom number) suddenly drops 15 points or more,
this is a dangerous warning sign. This usually means that the mother is bleeding
heavily. If you do not see any bleeding from her vagina, her placenta may have
detached and she might have bleeding inside (intrapartum haemorrhage).

Blood pressure goes up

Blood pressure of 140/90 mmHg or higher is a warning sign. The woman may have pre-
eclampsia, which can cause convulsions (eclampsia), detached placenta, bleeding in
the brain, or a severe haemorrhage. The baby may die and the mother may die as well. 
• Assess the progress of labour by checking uterine contractions (length, strength and
frequency) every 30 minutes, descent of the head every two hours and cervical dilatation every
four hours.
Uterine contractions

The frequency, length and strength of the contractions should be monitored and
recorded every half hour. Frequency indicates the number of contractions the woman
has in ten minutes. Count them. Length refers to the amount of time each contraction
lasts. Measure the time on your watch (if you have one). Strength indicates the severity
of pain experienced during each contraction; ask the mother to tell you about this.

In normal labour, as the labour progresses the contractions become more frequent, they
last longer, and they feel stronger to the mother (more painful).

3.2.3  Dilatation of the cervix

The progress of labour is usually assessed by the degree of dilatation of the cervix.
Cervical dilatation is assessed by doing a vaginal examination every four hours and
using your fingers to estimate how wide the cervix has opened. (We described how to
do this in Study Session 2). In normal labour the average rate for cervical dilatation is
one centimetre every hour (1 cm per hour).

3.2.4  Descent of the presenting part

You measure descent of the presenting part of the fetus by abdominal palpation in
relation to the pelvic brim. The descent of the presenting part can also be detected by
vaginal examination. This should be assessed and recorded every two hours during the
labour.

3.2.5  Discharges from the vagina

Show is the name given to the blood-stained mucus seen in early labour. Towards the
end of the first stage a trickle of blood may appear. Amniotic fluid may be seen trickling
from the vagina after the membranes have ruptured. The presence
of mechonium (mechonium is pronounced ‘mee-koh-nee-um’). Mechonium (dark-green
coloured discharge, which is the first stool of the baby) in the amniotic fluid suggests
fetal distress as it does not normally pass stool until after the birth.

3.2.6  Fetal condition
The fetal condition during labour can be assessed by obtaining information about the
fetal heart rate (the number of beats per minute) and its pattern in relation to the
mother’s contractions. Check the fetal heart rate every 30 minutes by listening
(auscultation).

• Nurses are responsible for monitoring any potentially serious complications during and after
delivery and acting immediately to prevent this situation.

5. Discuss the stages of labor.

We have 4 stages of labor. The first stage was the labor process. The second was the
fetal stage. The third was the placental stage. Lastly, the recovery.

The labor process is the first stage of labor. It is the dilation of the cervix. In this
stage, we have 3 phases. The latent, the active, and the transition. In the latent
phase which is also known as early labor, your cervix will gradually efface (thins out)
and dilates (opens) to about 1-3 centimeters (cm) by the end of this phase. It has a
duration 15-20 seconds. The interval and frequency is in every 5-15 minutes. In the
active phase, your cervix begins to dilate more rapidly and opens up further to 4-7
cm. Contractions are longer, stronger, and closer together. It has a duration 20-40
seconds. The interval and frequency are in every 3-5 minutes. In the transition
phase, during the last part of active labor, contractions are even longer, stronger, and
closer together – this can be the most difficult part of your entire labor. The cervix will
dilate and opens up further to 8-10 cm. It has a duration 40-60 seconds. The interval
and frequency are in every 1-3 minutes.

The fetal stage, the second stage of labor. Once the cervix is fully dilated, the baby
will be delivered or it is the final descent of the baby. We have the mechanism of labor.
The mechanisms of labor, commonly known as the cardinal movements, include
changes in the position of the fetus's head during labor. These are discussed in terms of
a vertex presentation. Although labor and delivery occur in a continuous manner, the
cardinal movements are characterized as the seven discrete sequences which are the
engagement, descent, flexion, internal rotation, extension, restitution and external
rotation, expulsion. The first mechanism of labor is engagement. It is when the widest
diameter of the presenting part (with a well-flexed head, where the largest transverse
diameter of the fetal occiput is the biparietal diameter) enters the maternal pelvis to a
level below the plane of the pelvic inlet. On the pelvic examination, the presenting part
is at 0 station, or at the level of the maternal ischial spines. The second mechanism of
labor is the descent. It is the downward passage of the presenting part through the
pelvis. This occurs intermittently with contractions. The rate is greatest during the
second stage of labor. The third mechanism of labor is the flexion, as the fetal vertex
descents, it encounters resistance from the bony pelvis or the soft tissues of the pelvic
floor, resulting in passive flexion of the fetal occiput. The chin is brought into contact
with the fetal thorax, and the presenting diameter changes from occipitofrontal (11 cm)
to suboccipitobregmatic (9.5 cm) for optimal passage through the pelvis. Another is the
internal rotation which is the fourth mechanism of labor. As the head descends, the
presenting part, usually in the transverse position, is rotated about 45° to
anteroposterior position under the symphysis. Internal rotation brings the
anteroposterior diameter of the head in line with the anteroposterior diameter of the
pelvic outlet. The fifth mechanism of labor is the extension, with further descent and
full flexion of the head, the base of the occiput comes in contact with the inferior
margin of the pubic symphysis. Upward resistance from the pelvic floor and the
downward forces from the uterine contractions cause the occiput to extend and rotate
around the symphysis. This is followed by the delivery of the fetus' head. The
restitution and external rotation are the sixth mechanism of labor. It is when the
fetus' head is free of resistance, it untwists about 45° left or right, returning to its
original anatomic position in relation to the body. The expulsion which the last
mechanism of labor. It is when after the fetus' head is delivered, further descent brings
the anterior shoulder to the level of the pubic symphysis. The anterior shoulder is then
rotated under the symphysis, followed by the posterior shoulder and the rest of the
fetus.

.
The placental delivery, the third stage of labor. This is the complete delivery of the
baby to the complete delivery of the placenta. In this stage, we have 3 signs of
placental separation, 2 types of placental delivery and 2 techniques of placental
delivery. In the 3 signs of placental separation, (1) we have the calkins sign, the
chance of shape of the uterus from discoid to ovoid. This is an indication of placental
separation from the uterine wall. (2) the lengthening of umbilical cord. (3) lastly, the
sudden gush of blood. Furthermore, in the 2 types of placental delivery, we have
the Schultze and Matthew Duncan delivery . In the Schultze method, these are
sometimes referred to as “Shiny Schultz.” The separation begins in the center of the
placenta (the fetal surface), and this part descends first, with the remainder following.
The Matthew Duncan separation method which are sometimes referred to as
“Dirty Duncan”, involves detachment of the leading edge of the placenta, and the entire
organ slips down and out of the uterus sideways. The 2 techniques of placental
delivery are the old and new technique. The old technique is the Brandt Andrews
Maneuver. This technique is for expressing the placenta from the uterus. One hand puts
gentle traction on the cord while the other presses the anterior surface of the uterus
backward. The new technique is the controlled cord counter traction. Controlled cord
traction (CCT) is traction applied to the umbilical cord once the woman's uterus has
contracted after the birth of her baby, and her placenta is felt to have separated from
the uterine wall, whilst counter-pressure is applied to her uterus beneath her pubic
bone until her placenta delivers.

The last stage of labor is the recovery. The recovery begins during the first 2-3 hours
after delivery. During this time, the uterus contracts here and there, pushing out what’s
left inside and reestablishing muscle tone. The contractions are hastened by
breastfeeding, which stimulates the production of the hormone oxytocin. During this
time, you may experience tremors and chills, discomfort from pain, episiotomy, tears,
or hemorrhoids, weakness and dizziness, especially while standing up and difficulty
urinating due to swelling in the genital area. The vital sign must be stabilized. The fever
on the first 24 hours after delivery is normal. If the patient is experiencing dehydration,
we have to increase the oral fluid intake. Fever after 24 hours after delivery may be an
indication of infection. We have to watch for hypovolemic shock.