OLIVAREZ COLLEGE

Dr. A. Santos Avenue, San Dionisio, Parañaque City

PACUCOA Accredited
COLLEGE OF HEALTH SCIENCES EDUCATION
NURSING DEPARTMENT

Normal Spontaneous Delivery

BSN II - GROUP A

Alamada, Alyzah Du Jules Angelo

Alegre, Estelle Elsisora, Christine
Almoguera, Clarisa Escobal, Kristene Ysabelle
Arat, Kayte Ann Kimberly Escubio, Oshia Cassandra
Baclea-an, Denice Ann Fernandez, Carl Hendrick
Bagaan, Marie Gatpo, Mia Lynn
Balingao, Leixter Win Gilbuena, Ilian Akiko
Belostrino, Jenalyn Maqrani, Ahmed
Bernardo, Andrea Maranan, Francine
Borela, Kassandra Mae Nadura, Girlie
Cabrera, Princess Camille Nuez, Chona Pearl
Calag, John Paul Oleo, Jhoana Marie
Carmona, Kassandra Oracion, Kimberly
Casim, Francine Orongan, Mary Rose
Cordenete, Jacinth Paculaba, Marc Efren
Corpuz, Humphrey Shane Pagcanlungan, Miguel
Daguinod, Celline Perdigon, Diana Elane

CLINICAL INSTRUCTORS

Anelie Sapanza, RN
Steve Arancillo, MAN, RN
Floriel Kris Caspe, RN, RM

December 2022
 FAMILY HISTORY

Analysis: The client’s family, starting with her parents, both of them don't have any existing illnesses
and maintenance drugs.

SOCIAL HISTORY:

The patient is both non-smoker and non-drinker.

a. Course in the Ward

Day 1

On October 19 2022 at 6:30 am, a patient at 38 5/7 weeks of gestation, cephalic in labor was admitted
with watery vaginal discharge. Patient’s Cervical Dilatation was 5cm at 7:30am, 6cm at 9:30 am, 8cm at
11:30am and lastly 10cm at 12:30pm and thus transferred to the delivery room.at 1:15 amniotomy and
perennial prep was done. Time of delivery was at 1:39pm to an alive baby girl, and the time of placental
expulsion was at 1:50pm.Perineal laceration sutured and perennial care was done accordingly, EINC
was done, Medications and Prophylaxis was administered accordingly. And at 3:40pm the patient
returned to the ward in an ambulatory state, medication and all needs were attended.

Day 2

And on october 20, 2022 the patient was in stable condition, vital signs were monitored and the uterus
was well contracted. And at 2:30pm the patient was discharged in good condition.

Discharge Diagnosis: G3 P3 (3003) NSD to an alive baby girl, 4.0 kg A/S 9/9 cephalic
Stages of Labor

First stage of Labor

Dilation of the cervix maximum of 15 hours.
During the first and second phases of labor,
the fetus descends. The cervix and vagina
dilate, and the muscles of the pelvic floor
and perineum shift, creating the birth canal.
Due to its connection to the uterus, the
bladder is dragged above the pubis, the
urethra is stretched, and the bowel is
compressed.

Second stage of Labor

Pushing is the term for the periodic contractions
of the front abdomen, pelvic floor, and diaphragm
that increase the force of uterine contractions.
They begin when the fetal head enters the pelvic
cavity, which occurs after full cervical dilation.

The effacement, dilatation, and labor mechanisms

are depicted in the figure. As uterine contractions
continue, the cervix widens, the lower uterine
segment (passive segment) thins, and the upper
uterus (active segment) thickens. The fetus enters
the vaginal canal and descends in this manner.

Third stage of Labor (Delivery of the Placenta)

Sign of placental separation

The uterus becomes globular in shape and firmer, the uterus rises in the abdomen, the umbilical cord
descends three inches or more further out of the vagina, and a sudden gush of blood.

Fourth stage of Labor (Recovery)

Within the first to fourth hour following delivery, the recovery stage starts. The uterus intermittently
contracts throughout this time, expelling the remaining matter and regaining muscle tone.
Breastfeeding, which promotes the synthesis of the hormone oxytocin, speeds up these contractions.