INTRODUCTION

The experience of labor is complex and subjective. Several factors affect a woman's perception
of labor making each experience unique. Labor is the active process of delivering a fetus and is
characterized by regular, painful uterine contractions which increase in frequency and intensity.

One unique aspect of childbirth is the association of this physiologic process with pain and
discomfort. However, the experience of pain during labor is not a simple reflection of the
physiologic processes of parturition. Instead, labor pain is the result of a complex and subjective
interaction of multiple physiologic and psychosocial factors on a woman’s individual
interpretation of labor stimuli. An understanding of labor pain in a multidimensional framework
provides the basis for a woman-centered approach to labor pain management that includes a
broad range of pharmacologic and non pharmacologic intervention strategies.

The labor process is the gateway towards a safe delivery. Once the woman has undergone
labor, it is imminent that delivery would follow suit. It is important for the woman to have a
smooth labor process for this is where she would be gathering her strength to deliver her
precious bundle of joy.

At this pregnancy stage of Belle, she will now be able to deliver her newborn. She is the center
of everything at this point of time. Belle must stay focused so the entire labor process would go
by smoothly and safely. Intervention for pain and discomfort during labor and birth is a major
part of modern obstetric care of laboring women.

OBJECTIVES

General Objectives

At the end of this case presentation, the participants and the audience will be:

● Educated about the Labor and Delivery, its nursing management and acquired
the proper knowledge, skills and attitude in providing care to the patient.

Specific Objectives

Knowledge
 ● Recognize the labor discomforts felt by the patient.
● Identify the predisposing and precipitating factors.
● Discuss the labor discomforts of pregnancy.

Skills

● Identify appropriate nursing diagnosis according to the needs of the client.

● Implement a nursing care plan in managing patient’s signs and symptoms using
the nursing process.
● Document correctly patient’s condition, nursing interventions and evaluation.

Attitude

● Recognize the patient's needs using a holistic approach.

● Facilitate Discharge planning
● Provide proper measures that are designed to promote feelings of competence in
self-management and infant care.

NURSING HEALTH HISTORY

A. Biographic Data

Patient’s Name: Belle

Address:
Age: 21 years old
Sex: Female
Marital Status: Single
Occupation: Fresh Graduate
Religion:
Source of Information: Patient Herself
Attending Physician:
Date of Admission: October 14, 2021
Time of Admission:
Chief Complaint: Labor pain
Admitting Impression: G1P1

B. Chief Complaint

Patient complained of labor pain that started 5 hours ago

C. Past Medical History

Patient had chicken pox at age 12

D. Family History

Patient’s father has asthma and mother has Hypertension

E. Lifestyle and Health Practices

AGE OF MENARCHE: 12 years old

LMP (LAST MENSTRUAL PERIOD): June 16, 2021

ALCOHOL/CIGARETTE USE?: Non-smoker and does not drink alcohol.

F. Obstetric History

MENSTRUAL CYCLE: 28 days

DURATION OF MENSTRUATION: 5 days

NUMBER OF PADS USED: 2 pads per day

SYMPTOMS FELT DURING MENSTRUATION: Dysmenorrhea (pain is tolerable)

 PHYSICAL EXAMINATION

Abdominal Assessment for bladder distention was performed. As your growing baby
expands, the bladder gets compressed, making less space for urine. Results revealed
that the patient's bladder is distended, she was then encouraged to void.

Rationale: Abdominal examination can be undertaken to assess progress and to help

make decisions regarding the care required by the woman during labour.
Abdominal examination is always carried out prior to auscultation and before fetal
monitoring (CTG). It is also done before performing the vaginal examination.

Vaginal assessment
Was done in order to assess cervical dilation. two fingers were inserted into the vagina
and the cervix was felt with finger tips. Results revealed that the patient was 3cm and
50% effaced.

Rationale: Determine if true labour has begun and the stage it has reached, based on
measuring the dilatation of the cervix.
Cervical dilatation is the increase in diameter of the cervical opening, estimated in
centimeters.

Fetal Heart Rate monitoring was also done to the patient. The stethoscope was slowly
moved up and down until the sound was heard. Fetal heart rate was audible and the
result was 140 beats per minute. The finding showed that the fetal heart rate is in it’s
normal range of 110-160 bpm during labor.

Rationale: A baby’s heart rate can help doctors determine if pregnancy and labor are
progressing normally. Changes in the baby’s heart rate can be a sign of a potential
problem.
 ANATOMY AND PHYSIOLOGY

This section addresses the salient anatomical changes of the embryo and fetus during the gestational
period and will also briefly mention the changes in the pregnant woman during the course.

Labor is a local process that involves the abdomen and reproductive organs, but its intensity is so great
that almost all body systems are affected by it.

Cardiac Output

Each contraction greatly decreases blood flow to the uterus because the contracting uterine wall puts
pressure on the uterine arteries. This increases the amount of blood that remains in a woman's general
circulation, leading to an increase in peripheral resistance, which in turn results in an increase in systolic
and diastolic blood pressure. Labor involves strenuous work and effort and requires a response from the
cardiovascular system.

Blood Pressure

With the increased cardiac output caused by contractions during labor, systolic blood pressure rises an
average of 15 mm Hg with each contraction. When a woman lies in a supine position and pushes during
the second stage of labor, pressure of the uterus on the vena cava causes her blood pressure to drop
precipitously, leading to hypotension. An upright or side-lying position during the second stage of labor
not only makes pushing more effective but also can help avoid such a problem

Hematopoietic System

The major change in the blood-forming system that occurs during labor is the development of
leukocytosis, or a sharp increase in the number of circulating white blood cells, possibly as a result of
stress and heavy exertion. At the end of labor, the average woman has a white blood cell count of
25,000 to 30,000 cells/mm³, compared with a normal count of 5000 to 10,000 cells/mm³.

Respiratory System

Whenever there is an increase in cardiovascular parameters, the body responds by increasing the
respiratory rate to supply additional oxygen. Total oxygen consumption increases by about 100% during
the second stage of labor. It can result in hyperventilation. Using appropriate breathing patterns during
labor can help avoid severe hyperventilation.
Temperature Regulation

The increased muscular activity associated with labor can result in a slight elevation (1° F) in
temperature. Diaphoresis occurs with accompanying evaporation to cool and limit excessive warming.

Fluid Balance

Because of the increase in rate and depth of respirations (which causes moisture to be lost with each
breath) and diaphoresis, insensible water loss increases during labor. Fluid balance is further affected if
a woman eats nothing but sips of fluid or ice cubes or hard candy. Although not a concern in usual labor,
the combination of increased fluid losses and decreased oral intake may make intravenous fluid
replacement necessary if labor becomes prolonged.

Urinary System

With a decrease in fluid intake during labor and the increased insensible water loss, the kidneys begin to
concentrate urine to preserve both fluid and electrolytes. Pressure of the fetal head as it descends in the
birth canal against the anterior bladder reduces bladder tone or the ability of the bladder to sense filling.
Therefore, unless the woman is asked to void approximately every 2 hours during labor, overfilling may
occur, possibly decreasing bladder tone in the postpartum period.

Musculoskeletal System

All during pregnancy, relaxin, an ovarian-released hormone, has acted to soften the cartilage between
bones. In the week before labor, considerable additional softening causes the symphysis pubis and the
sacral/coccyx joints to become even more relaxed and movable, allowing them to stretch apart to
increase the size of the pelvic ring by as much as 2 cm. A woman may report this increased pubic
flexibility as increased back pain or irritating, nagging pain at the pubis as she walks or turns in labor.

Gastrointestinal System

The gastrointestinal system becomes fairly inactive during labor, probably because of the shunting of
blood to more life sustaining organs and also because of pressure on the stomach and intestines from
the contracting uterus. Digestive and emptying time of the stomach becomes prolonged.
Neurologic and Sensory Responses

The neurologic responses that occur during labor are responses related to pain (increased pulse and
respiratory rate). Early in labor, the contraction of the uterus and dilatation of the cervix cause the
discomfort. This pain is registered at uterine and cervical nerve plexuses (at the level of the 11th and
12th thoracic nerves). At the moment of birth, the pain is centered on the perineum as it stretches to
allow the fetus to move past it.

Changes to the cervix

As labour gets closer, your cervix softens and becomes thinner, getting ready for the
dilation (widening) that will allow the baby to enter the vagina. You may also see a
'show', which is a pinkish plug of mucus, stained with blood.

Engagement
Your baby may move further down your pelvis as the head engages, or sits in place
over your cervix, ready for the birth. Some women feel they have more room to breathe
after the baby has moved down. This is called 'lightening'.

Rupture of the membranes, or 'waters breaking'

Some women find the sac of amniotic fluid containing the baby breaks before labour,
contractions start and the fluid runs (or gushes) out of the vagina. This is referred to as
rupture of the membranes, or 'waters breaking'.

The Hormones:

Prostaglandin- Before childbirth, a higher level of prostaglandin will help open the
cervix and make your body more receptive to another important hormone, oxytocin.

Oxytocin- This hormone causes contractions during labour, as well as the contractions
that deliver the placenta after the baby is born. These post-birth contractions, including
more that can occur during breastfeeding, help your uterus shrink back to its normal
size. Oxytocin and prolactin are the two main hormones that produce and let down
breast milk for your baby. Skin-to-skin contact between a mother and baby helps to
release more of these hormones.
Relaxin- The hormone relaxin helps soften and stretch the cervix for birth, while helping
your waters break and stretching the ligaments in your pelvis to allow the baby to come
through.

Psychological Responses of a Woman to Labor

labor can lead to emotional distress because it represents the beginning of a major life change for a
woman and her partner.

Physiologic Effects of Labor to a Fetus

Although a fetus is basically a passive participant in labor, the pressure and circulatory changes that
occur with contractions cause detectable physiologic changes.

Neurologic System

Uterine contractions exert pressure on the fetal head, so the same response that is involved with any
instance of increased intracranial pressure occurs. The fetal heart rate (FHR) decreases by as much as 5
beats per minute (bpm) during a contraction, as soon as contraction strength reaches 40 mm Hg. This
decrease appears on a fetal heart monitor as a normal or early deceleration pattern.

Cardiovascular System

The ability to respond to cardiovascular changes is usually mature enough that the fetus is unaffected by
the continual variations of heart rate that occur with labor-a slight slowing and then a return to normal
(baseline) levels. During a contraction, the arteries of the uterus are sharply constricted and the filling of
cotyledons almost completely halts. The amount of nutrients, including oxygen, changed during this
time is reduced, causing a slight but consequential fetal hypoxia. Increased intracranial pressure caused
by uterine pressure on the fetal head serves to keep circulation from falling below normal during the
duration of a contraction.

Integumentary System
 The pressure involved in the birth process is often reflected in minimal petechiae or ecchymotic areas
on a fetus (particularly the presenting part). There may also be edema of the presenting part (caput
succedaneum).

Musculoskeletal System

The force of uterine contractions tends to push a fetus into a position of full flexion, the most
advantageous position for birth.

Respiratory System-

The process of labor appears to aid in the maturation of surfactant production by alveoli in the fetal
lung. The pressure applied to the chest from contractions and passage through the birth canal helps to
clear it of lung fluid. For this reason, an infant born vaginally is usually able to establish respirations
more easily than a fetus born by cesarean birth.

DIAGNOSTIC AND LABORATORY

Hematology
- Hematology tests include tests on the blood, blood proteins and blood-producing
organs. These tests can evaluate a variety of blood conditions including infection,
anemia, inflammation, hemophilia, blood-clotting disorders and leukemia.

Here is the Hematology test result of Belle:

Examination Result Units Reference Significance

Value

CBC
 Hemoglobin 142 g/L 1.35-1.80 Normal

Hematocrit 0.41 Vol.Fr 0.40-0.54 Normal

RBC 4.41 10^12/L 4.2-6.0 Normal

WBC 6.4 10^g/L 4.5-11 Normal

:
Urinalysis
- urinalysis is a set of screening tests that can detect some common diseases. It
may be used to screen for and/or help diagnose conditions such as a urinary
tract infections, kidney disorders, liver problems, diabetes or other metabolic
conditions

Belle’s Urinalysis result

Physical Properties

Color Straw

Transparency Hazy

Reaction 5.0 (acidity)

Specific Gravity 1.025

Chemical Tests

Sugar Negative

Albumin Negative

Microscopic Findings
- It can see cells from your urinary tract, blood cells, crystals, bacteria, parasites,
and cells from tumors. This test is often used to confirm the findings of other tests
or add information to a diagnosis.

Results:
Pus Cells Occasional (0-3)
RBC Occasional (2-4)
 DRUG STUDY

Name of Patient: Belle Impression/Diagnosis: G1P0

Age & Sex: 21 years old/Female Ward/Bed:

CLASSIFICATIO INDICATION & SIDE EFFECTS SPECIAL NURSING

NAME OF DRUG N & MECHANISM CONTRAINDICA OR ADVERSE PRECAUTION RESPONSIBILIT
OF ACTION TION EFFECTS Y

Lactated Ringer’s Classification: Indication: Side Effects: Additives may be

in 5% dextrose Lactated Ringers in Treatment for incompatible with
5% Dextrose persons needing Agitation, back Lactated Ringer's
Chemical Name: belongs to a class of extra calories who pain, bluish color Injection. As with >Do not
D5LR drugs called cannot tolerate of the skin. all parenteral administer unless
Intravenous fluid overload. burning, crawling, solutions, the solution is
Route of Nutritional Treatment of itching, compatibility of clear and the
Administration: Products. shock. numbness, the additives with container is
Intravenously prickling, "pins the solution must undamaged.
Hypertonic Contraindication: and needles", or be assessed
Dosage: Nonpyrogenic Lactate tingling feeling, before addition,
1000 mL @ 30 Parenteral fluid administration is chest pain, by checking for a >Solution
gtts/min Electrolyte contraindicated in discomfort, or possible color containing
Nutrient replenisher
severe metabolic tightness. change and/or the dextrose should
acidosis or decreased heart appearance of be used with
alkalosis, and in rate, precipitates, caution in patients
Mechanism of severe liver decreased urine insoluble with known
Action: Hypertonic disease or anoxic output and complexes, or subclinical or
solutions are states which difficulty of crystals. overt diabetes
those that have affect lactate breathing.
an effective metabolism.
osmolarity greater Solutions
than the body containing
fluids. This pulls dextrose may be
the fluid into the contraindicated in
vascular by patients with mellitus
osmosis resulting hypersensitivity to
in an increased corn products.
vascular volume. >Discard unused
It raises portions.
intravascular
osmotic pressure >Properly label the
and provides fluid, IV Fluid
electrolytes and
calories for >Observe aseptic
energy. technique when
changing IV fluid
 NURSING CARE PLAN

Name of Patient: Belle Impression/Diagnosis: G1P1

Age & Sex: 21 Y.O /F Ward/Bed:

DEFINING NURSING OUTCOME NURSING

CHARACTERISTICS DIAGNOSIS IDENTIFICATION/O INTERVENTION RATIONALE EVALUATION
BJECTIVE

SUBJECTIVE: Acute pain related SHORT TERM: INDEPENDENT: Attitudes and Client will have a
Patient Belle to effects of labor After 2 hours of 1. Assess degree reactions to pain normal delivery.
complains of labor and delivery nursing of discomfort are individual and
pain that started 5 process. intervention: through verbal based on past
hours ago. and nonverbal experiences, Client has the
a.) Client will cues; note cultural understanding of ability to
OBJECTIVE: RATIONALE: report discomfort practices on pain physiological understand the
is minimized. response. changes, and usual process of
Vital signs: Labor pain is cultural labor.
T = 37.1°C caused by expectations.
PR = 88 bpm contractions of the 2. Assess nature Client reports that
RR = 20cpm muscles of the LONG TERM: and amount of she feels
Bp = 130/70 uterus and by At the end of vaginal show, comfortable.
mmHg pressure on the nursing cervical dilation,
Weight = 140 lbs cervix. intervention: effacement, fetal
a.) Patient will station, and fetal
Fetal Heart Rate: NOTE: Nursing express relief descent.
140 bpm Diagnosis should obtained from
be based on the labor pain.
(NANDA – b.) Patient will 3.Time and record
Approved Nursing have a normal the frequency,
Diagnosis) delivery intensity, and
c.) Patient will duration of the
have the ability to uterine contractile Monitor the labor
understand the pattern per progress and
usual process of protocol. provide
labor information for
4. Provide positive the client.
reinforcement and
encouragement to
patient.

DEPENDENT: Gives the patient

Start D5 Lactated sense of control
Ringer 1000 mL to and confidence
run at 30
gtts/mins.

Serves as medium
for IV medications

To replace fluid
and electrolyte
loss.
DEFINING NURSING OUTCOME NURSING NURSING
CARE PLAN
CHARACTERISTICS DIAGNOSIS
Name of Patient: Belle IDENTIFICATION/O INTERVENTION G1P1RATIONALE
Impression/Diagnosis: EVALUATION
Age & Sex: 21 Y.O / F BJECTIVE Ward/Bed:

SUBJECTIVE: Situational Low SHORT TERM: INDEPENDENT: Client will

Patient Belle Self-Esteem After 2 hours of 1. Provide Failure and lack of verbalize
verbalized “Why related to nursing reinforcement for self-esteem have acceptance of self
does this hurt so situational crisis intervention: positive actions, been problems for as an increased
badly? I wish my of pregnancy with and encourage this client, who sense of worth.
boyfriend was a.) The patient will
loss of control report discomfort is
client to accept needs to learn to
here.” while
over life events. minimized. this input. accept self as an
holding her
individual with Client can express
abdomen enduring
labor pain. positive attributes her preferences
during pregnanct.
RATIONALE:
OBJECTIVE: Situational low The client often
esteem is having a LONG TERM: 2. Encourage has lost respect Client would be
Vital signs: negative perception of At the end of expression of for self and has a able to verbalize
T = 37.1°C
self or capabilities in nursing feelings of anger, notion that the her feelings about
response to change or intervention:
PR = 88 bpm guilt, and shame. situation is her experiences
loss that changes
RR = 20cpm situation. hopeless. during her
Bp = 130/70 mmHg a.) Client will labor/pregnancy
Expression of
Weight = 140 lbs identify feelings period.
these feelings
and methods for
enables the client
Fetal Heart Rate: coping with a low
to begin to accept
140 bpm NOTE: Nursing perception of self.
responsibility for
Diagnosis should be
self and initiate
based on the
steps to make
(NANDA –
Approved Nursing changes.
Diagnosis)
DEPENDENT:

Start D5 Lactated Serves as medium

Ringer 1000 mL to for IV medications
run at 30 gtts/mins.
To replace fluid and
electrolyte loss.
 DISCHARGE PLAN/ HEALTH TEACHING

EVALUATION

Patient Belle was assessed last October 14, 2021, with a chief complaint of labor pain
for 5 hours. She presented her laboratory results which revealed normal. She was
assessed, encouraged to void and placed on NPO while in active labor. Belle is now in
the stage of Labor and Delivery.

Internal examination was performed with a result of 10 cm cervical dilation, ROM and
Bloody show, Patient was transferred to delivery room per stretcher. After an hour, Belle
delivered an alive baby girl via NSVD.

The goals in the nursing care plan were met because the patient is now free from labor
pain for she had delivered her newborn via Normal Spontaneous Vaginal Delivery and
is able to understand the process of labor. The objectives of this case were reached as the
group identified the patient's needs, facilitated discharge planning, provided complete care
during labor as well as comprehensive information for the patient's well being.

DISCHARGE PLAN

Patient was taught and counseled about the proper measures that are designed to
promote the woman’s feelings of competence in self-management and infant care. The
group then scheduled follow-up after discharge.