INTRODUCTION

Pregnancy is a state of having implanted products of conception located either in the uterus or

elsewhere in the body. It ends through either spontaneous or elective abortion or delivery. During this

time, the mother’s body goes through immense changes involving all organ systems to sustain the

growing fetus. Pregnancy usually lasts about 40 weeks, or just over 9 months, as measured from the last

menstrual period to delivery. Health care providers refer to three segments of pregnancy, called

trimesters. First Trimester (Week 1 to Week 12), Second Trimester (Week 13 to Week 28), Third

Trimester (Week 29 to Week 40).

This is the case of a female patient, Ms. Eljean, 30 years old, living in Kenram, Isulan Sultan

Kudarat. She was admitted at Sultan Kudarat Provincial Hospital last November 24, 2023 at 11:35 pm.

She was diagnosed with G3P3 (2003) pregnancy uterine delivered term cephalic live baby Boy

AS ( Apgar score) 8.9 BW 3,000q by Normal Spontaneous Vaginal Delivery (NSVD), Pre labor rupture of

Membrane.

Normal spontaneous vaginal delivery ( NSVD ) is when a woman goes into labor without the aid

of any labor inducing drugs or methods, and Is able to deliver the baby without requiring a

doctor’s aid through cesarean Section, vacuum extraction, or with forceps. This common form of

delivery is considered to be the safest method of childbirth. If the safety of the mother Or baby

is at risk, a different method of delivery may be used. For example, A cesarean section may be

necessary if the aby is not positioned with the head downward, if the baby is in distress, or if

the baby is unable to pass Through the pelvis due to size. In the year 2013, out of the nearly

four million births in the United states, there were approximately three million were Vaginal

deliveries. In Australia in 2009, 70 percent of women delivered vaginally.

Most health expert, including World Health Organization(WHO), do recommend vaginal delivery

for women whose babies have Reached full term. In comparison to other methods of childbirth,

vaginal delivery is the simplest process of delivery.

 Objectives of the Study

General Objectives:

After reading this case, the readers will be able to understand and analyze the important

Information about the researches and analysis presented in this case study. It will give the readers

A better understanding about the client’s condition.

Specific Objectives:

After about 2 hours of reading this case, the readers will be able to:

1) Analyzed the brief summary of introduction that can present a concise overview of this study

2) Identified correctly the important information regarding the collected patients data

By presenting the following:

a) Vital Information

b) Background of the family

c) History of Past Illness

d) History of Present Illness

e) Effect and expectations of the family and the patient to the illness

f) Genogram

3) Physical Assessment is Understood

4) Discussed comprehensively the complete diagnosis of the client based on Textbook Discussion

5) Determined and discussed briefly the anatomy and physiology of the body system involved

6) List the actual and possible signs and symptoms that our patient may manifest

7) Interpreted the laboratory and other diagnostic results to the client

8) Presented the drugs that the physician ordered for the wellness of the client

9) Analyzed the prognosis

10) Listed all the references used in the study

 PATIENT’S DATA

Vital Information

Patients Name: Ms. Eljean

Age: 30 years old

Sex: Female

Birth Date: July 27, 1993

Birth Place: Davao City

Address: Kenram, Isulan, Sultan Kudarat

Occupation: Housewife

Tribe: Ilocano

Citizenship: Filipino

Religion: Jehuvas Witness

Civil Status: Single

Educational Attainment: . Junior High School Graduate

Name of Institution: Sultan Kudarat Provincial Hospital

Date and Time of Admission: November 24, 2023 @ 11:35 pm

Chief Complaint: Labor pain watery vaginal discharge

Post-Operative Diagnosis: G3P2 Pregnancy Uterine 39 5/7 weeks AOG, Cephalic in Latent
Phase of Labor , Prom.

Attending Physician: Elaine M. Avance, RN, MD

Spouse Name: Mr. Jimuel

Age: 29 years old

Educational Attainment: Junior High School Graduate

Occupation: Security Guard

Parents Name

Father’s Name: Mr. Elmer

Age: 55 years old

Occupation: Deceased

Educational Attainment: High school Graduate

Mother’s Name: Billy Jean Castillo

Age: 53 years old

Occupation: Cook

Educational Attainment: High School Graduate

Siblings:

Name Age Educational Attainment

Elizar 28 High School Graduate

Clea Monique 23 High School Graduate

Elmer Jr. 20 High School Graduate

Source of Income: Patient’s spouse

Source of Information: Patient

 Patient ‘s Chart

Family Background

Ms. Eljean is a 30 years old woman living in Kenram, Isulan Sultan Kudarat. Their religion is Jehuvas

witness. She is not yet married to her current live in partner, Mr. Jimuel but they are planning to get

married soon. Mr. Jimuel is working as a security guard while Ms. Elhean is a house wife, busy taking care

of her children and her live in partner. They have three children. Chrish Jean, their first born is 11 years

old, Chirstian is 10years old, and Kyle, he is three days old when we interviewed them. Ms. Eljean

Mother is Mrs. BillyJean 46 years old, she is a cook. While her father, Mr. Elmer died last 2012. She has

3 siblings, Elizar 28 years old working as a labor, Clea Monique 23 years old working in a salon and Elmer

Jr. 20 years old is currently in Cebu city working as a labor also. While Mr. Jimuel has 4 siblings but one

of them died like his father. The client is knowledgeable of a good lifestyle like completing her pre-natal

check-ups and taking vitamins for her pregnancy.

History of Past Illness

As verbalized by the patient, she had no history of severe illnesses and history of surgical

procedure. She admits that she experiences common Illnesses like flu, cold and fever. She

also claim that she is Anemic, but other than that she has no illness.

History of Present Illness

The patient admits that she is experiencing signs and symptoms of being pregnant like

nausea, vomiting, and morning sickness. Her appetite is also not that good because she

is sensitive to smell and will vomit everytime she smell something bad for her. She was admitted

because of labor pain, few hours PTA (Prior to admission) with watery vaginal discharge hence this

admission.

Effects to Self

When she knew she was pregnant, she felt happy because this is not her first baby it is her

third time, so she already knew what to do and how to properly took care of her baby.
Although after pregnancy, she experiences insecurities because of her body but thanks to

her live in partner, he always boost her confidence everytime she felt insecure.

Effects to Family

When her family and live in partner knew about her being pregnant, they were so happy because

another member of the family will come. They wholeheartedly accept her pregnancy like what

they did to her first and second born children. When they knew that the baby is about to go out

they were all excited and can’t wait to see the other member of their family.

Expectations to Self

She is expecting that she will be a good mother to her children and will take good care of them.

She will do anything to be a good mother and she said that she will put her children first

above herself. She will do anything to give them a good and better life so that they will not

suffer and for them to have a good future. She will teach them good things so that her

child won’t become like others that has no manners. She is also expecting that she and her

live in partner will get married soon. With the help of her family and live in partner she will

get through these and will recover quickly.

 GENOGRAM

Legends:

🟥- Male

- Female

- deceased

- Hypertension

- Diabetes

--- - Not Blood Related

—Blood related
 Review of System

Date: November 28, 2023

Time: 9:00 am

General Survey:

Received patient siting on bed, observing her baby while sleeping. Without ongoing IVF and

ready to discharge. The patient is conscious, She denies that she is not experiencing any pain, and her

delivery was normal. The patient was cooperating well while we are assessing her Vital signs , physical

assessment and her history background.

Skin/Hair/Nails:

The patient skin was smooth and no rashes , lumps, sores, and itchiness of the skin, and also the hair is

moderately thick no signs of lice. The nails are clean, firm, and no presence of clubbing.

Head:

The patient denies having any head injury and trauma.

Eyes:

The patient denies of having blurry of vision, pain, history of glaucoma and cataracts. She denied

using grade glasses.

Ears:

The patient denied having hearing loss or ear pain. She also stated that she cleans her ears.

Nose:

The patient denies loss of smell, the nose is symmetrical and no signs of bumps.
Mouth and throat:

The patient denies of having sore throat or pain in the mouth or throat. And she claims

that she is drinking a lot of water each day.

Neck:

The patient neck have some small moles and no lesions or bumps.

Abdomen:

The patient denies abdominal pain and itching.

Respiratory system:

The patient denies trouble in breathing and no cough.

Cardiovascular system:

The patient claims that she’s not having a chest pain and palpitations.

Musculoskeletal:

The patient claims that she is not having joint stiffness, back pain and fatigue.

Gastrointestinal system:

The patient denies having constipation or diarrhea nausea and vomiting.

Endocrine system:

The patient denies having enlargement of the thyroid gland or inflammation of lymph nodes.

Breast:

The patient denies having masses in her breast, and denies of having history of breast cancer.
Genitourinary:

The patient claims that she is not experiencing pain while urinating.

Hematology:

The patient denies looking cyanotic these past few days.

Psychiatric:

The patient denies that she is not experiencing trouble in sleeping, depression, anxiety

and claims that she in not irritable.

 Physical Assessment

Date: November 24, 2033

Time: 11: 34 pm

General Survey:

Received patient siting on bed, observing her baby while sleeping. Without ongoing IVF and ready to

discharge. The patient is conscious, She denies that she is not experiencing any pain, and her delivery

was normal. The patient was cooperating well while we are assessing her Vital signs , physical

assessment and her history background.

Vital signs:

BP:110/70mmHg TEMP: 35.5 ℃ 02SAT: 96% PR:71 bpm RR:20 cpm

Head/Hair/Scalp:

Inspection: The head is round , the hair is moderately thick no dandruff noted, hair is long and

evenly distributed and black in color. No lesions noted.

Palpation: no tenderness and masses noted.

Face:

Inspection: the face is symmetrical, skin is white in complexion. No pimples noted. No scars and

edema noted.

Palpation: there is no masses and tenderness noted. Skin is smooth.

Eyes:

Inspection: the eye is symmetrical, and eyebrow is thin black in color and its evenly distributed,

eyelid are able to close completely. Eyelashes directed outward and intact. Pupils are equals in size,

round in shape and reacts to light and accommodation. Conjunctiva is pinkish in color, sclera is well

lubricated, whitish in color, the cornea is clear and transparent, iris is black in color. There is no difficulty

in eye movement.
Nose:

Inspection: the external nose is symmetrical, align at the midline, mucosa is moist, nasal septum

is intact, no lesions and nose deformities noted. Presence of blackheads noted.

Palpation: there is no tenderness noted.

Ears:

Inspection: ears are symmetrical, normal in size, no lesions noted, auricle is aligned to the outer

canthus of the eye, pinna recoils when folded.

Palpation: no tenderness or enlargement of lymph nodes noted.

Lips and Mouth:

Inspection: lips is pale in color with dry texture, the tongue is pinkish in color with white patches,

mobile and positioned at the midline. No dentures noted with incomplete set of teeth. Gums and

mucosa is pink and no lesion noted. Tonsils are not inflamed; uvula is bell in shape, pinkish in color, and

at the midline.

Neck:

Inspection: jugular veins are not inflamed and no stiffness noted.

Palpation: lymph nodes at the neck are not palpable. There is no enlargement of thyroid gland

upon palpation.

Breast:

Inspection: breast is asymmetrical and no sign of bumps.

Lungs:

Auscultation: breathing pattern is normal and no irregular rhythm noted. No crackles or stridor noted.
Heart:

Auscultation: no abnormal sound noted. Rate is within normal range.

Abdomen:

Inspection: no bumps, scars noted upon inspection.

Auscultation: no abnormal sound noted and abdomen is palpable.

Extremities:

Inspection: extremities are proportionate to the trunk; skin is brown in complexion, symmetrical

on both upper and lower extremities, no difficulties in performing flexion and extension. Muscle has

equal strength, able to grasp noted. No edema noted. There are scars from mosquito bites on her feet

and a bit larger scar in her right knee.

Skin:

Inspection: fair complexion, no lesion and hair is evenly distributed.

Palpation: no masses and tenderness noted. Warm to touch and has a smooth skin.

Nails:

Inspection: nails are trimmed and pinkish in color no presence of dirt under nail beds, capillary

refill after 3 seconds

 TEXTBOOK DISCUSSION

COMPLETE DIAGNOSIS

A spontaneous vaginal delivery is a vaginal delivery that happens on its own, without requiring doctors
to use tools to help pull the baby out. This occurs after a pregnant woman goes through labor. Labor
opens, or dilates, her cervix to at least 10 centimeters. (Erica Cirino, 2017)

When a woman goes into labor without the aid of any labor inducing drugs or methods, and is able to
deliver the baby without requiring a doctor’s aid through cesarean section, vacuum extraction, or with
forceps, this is known as a normal spontaneous vaginal delivery (NSVD). This common form of delivery is
considered to be the safest method of childbirth. If the safety of the mother or baby is at risk, a different
method of delivery may be used. For example, a cesarean section may be necessary if the baby is not
positioned with the head downward, if the baby is in distress, or if the baby is unable to pass through
the pelvis due to size. (NYE Partners in Women’s Health, 2007)

Vaginal delivery is a natural process that usually does not require significant medical intervention.
Management guided by current knowledge of the relevant screening tests and normal labor process can
greatly increase the probability of an uncomplicated delivery and postpartum course. All women should
be screened for group B streptococcus; women who test positive should be treated with antibiotics
during labor. Routine human immunodeficiency virus screening of all pregnant women, and treatment
with antiretroviral medication for those who test positive, can reduce perinatal transmission of the
infection. Once a woman is in labor, management should focus on the goal of delivering a healthy
newborn while minimizing discomfort and complications for the mother. In a patient who tests negative
for group B streptococcus, delaying admission to the labor ward until she is in active labor decreases the
number of possible medical interventions during labor and delivery. Once a patient has been admitted to
the hospital, providing her with continuous emotional support can improve delivery outcomes and the
birthing experience. Epidural analgesia is effective for pain control and should not be discontinued late in
labor to reduce the need for operative vaginal delivery. Epidurals prolong labor, but do not increase the
risk of cesarean delivery. Research has shown that labor may not progress as rapidly as historically
reported; this should be considered before intervening for dystocia. Routine episiotomy increases
morbidity and should be abandoned. Once the infant has been delivered, active management of the
third stage of labor decreases the risk of postpartum hemorrhage. (Dale A. Patterson,MD, Marguerite
Winslow,MD, & Coral D. Matus MD, 2018)
Signs and Symptoms

There are several signs that labor might be starting, including:

Contractions or tightenings

A “show”, when the plug of mucus from your cervix (entrance to your womb, or uterus) comes away

Backache

An urge to go to the toilet, which is caused by your baby’s head pressing on your bowel

Your waters breaking

Laboratory Test

Your first visit to the obstetrician should have included a full physical, urine (pee) test, and blood test to
check for things like:

Your blood type and Rh factor. If your blood is Rh negative and your partner’s is Rh positive, you may
develop antibodies that prove dangerous to your fetus. This can be prevented through an injection given
around the 28th week of pregnancy.

Anemia, a low red blood cell count

Hepatitis B, syphilis, and HIV

Immunity to German measles (rubella) and chickenpox (varicella)

Cystic fibrosis and spinal muscular atrophy. Health care providers now routinely offer to screen for these
disorders even when there’s no family history.

You can expect to get your urine tested and your weight and blood pressure checked at every (or almost
every) visit until you deliver. These tests can identify conditions such as gestational diabetes and
preeclampsia (dangerously high blood pressure).

.
Imaging Test

The following images studies may be used to assess women for normal spontaneous vaginal delivery.

Ultrasound: An ultrasound is a safe and painless test that uses sound waves to make images that show
the baby’s shape and position in the uterus. Third-trimester ultrasounds can examine the placenta, and
sometimes are part of a test called a biophysical profile (BPP) to see whether the baby is getting enough
oxygen. Women with high-risk pregnancies may have multiple ultrasounds in their third trimester.

Glucose screening: This test checks for gestational diabetes, a short-term form of diabetes that develops
in some women during pregnancy and can cause health problems for the baby, especially if it is not
diagnosed or treated. You’ll drink a sugary liquid, then have a blood test an hour later to check glucose
levels.

Group B strep test: Between your 35th and 37th weeks of pregnancy, the doctor will check you for group B
streptococcus (GBS) infection. GBS bacteria are found naturally in the vaginas of many women but can
cause serious infections in newborns. This test involves swabbing the vagina and rectum. A woman
whose test comes back positive must go to the hospital as soon as labor begins so that intravenous (IV)
antibiotics can be started to help protect the baby from becoming infected.

Nonstress test: A nonstress test (NST) is usually done when a health care provider wants to check on the
health of the fetus, such as in a high-risk pregnancy or when the due date has passed. The test checks to
see if the baby responds normally to stimulation and is getting enough oxygen. A baby that doesn’t
respond isn’t necessarily in danger, but more testing might be needed.

Contraction stress test: This test stimulates the uterus with pitocin, a synthetic form of oxytocin (a
hormone secreted during childbirth), to determine the effect of contractions on fetal heart rate. It may
be recommended when an earlier test indicated a problem and can see whether the baby’s heart rate is
stable during contractions.

Causes of Normal Spontaneous Vaginal Delivery

A spontaneous vaginal delivery is a vaginal delivery that happens on its own, without requiring doctors
to use tools to help pull the baby out. This occurs after a pregnant woman goes through labor. Labor
opens, or dilates, her cervix to at least 10 centimeters.

Labor usually begins with the passing of a woman’s mucous plug. This is a clot of mucous that protects
the uterus from bacteria during pregnancy. Soon after, a woman’s water may break. This is also called a
rupture of membranes. The water might not break until well after labor is established, even right before
delivery. As labor progresses, strong contractions help push the baby into the birth canal.

The length of the labor process varies from woman to woman. Women giving birth for the first time tend
to go through labor for 12 to 24 hours, while women who have previously delivered a child may only go
through labor for 6 to 8 hours.

These are the three stages of labor that signal a spontaneous vaginal delivery is about to occur:

Contractions soften and dilate the cervix until it’s flexible and wide enough for the baby to exit the
mother’s uterus.

The mother must push to move her baby down her birth canal until it’s born.

Within an hour, the mother pushes out her placenta, the organ connecting the mother and the baby
through the umbilical cord and providing nutrition and oxygen.

For spontaneous delivery, women must supplement uterine contractions by expulsively bearing down. In
the 2nd stage, women should be attended constantly, and fetal heart sounds should be checked
continuously or after every contraction. Contractions may be monitored by palpation or electronically.

Pharmacotherapy

Pharmacologic analgesia includes systemic opioids, nitrous oxide, epidural anesthesia, and pudendal
block. Although epidurals provide better pain relief than systemic opioids, they are associated with a
significantly longer second stage of labor; an increased rate of oxytocin (Pitocin) augmentation; assisted
vaginal delivery; and an increased risk of maternal hypotension, urinary retention, and fever. Cesarean
delivery for abnormal fetal heart tracings is more common in women with epidurals, but there is no
significant difference in overall cesarean delivery rates compared with women who do not have
epidurals. Discontinuing an epidural late in labor does not increase the likelihood of vaginal delivery and
increases inadequate pain relief.
Surgery

C-sections are unexpected emergency deliveries done when problems arise with the mother and/or
baby during pregnancy or labor. An emergency C-section might be done if:

Labor stops or isn’t moving as it should (and medicines aren’t helping)

The placenta separates from the uterine wall too soon (called placental abruption)

The umbilical cord becomes pinched (which could affect the baby’s oxygen supply) or enters the birth
canal before the baby (called umbilical cord prolapse)

The baby is in fetal distress — certain changes in the baby’s heart rate may mean that the baby is not
getting enough oxygen

The baby’s head or entire body is too big to fit through the birth canal

Normal Spontaneous Vaginal Delivery vs. C-Section

For most women, a vaginal birth is safer and healthier. Vaginal birth cuts the risk for many complications.
With a vaginal birth, a woman has the following:

A lower risk of needing a blood transfusion

A reduced risk of a postpartum infection. This includes a uterine infection. If you get an infection, you
may need to go to the hospital again within the first two months after birth.

A lower risk of internal uterine scarring. This can cause fertility or birth problems in the future. You may
have an ectopic pregnancy or your placenta may attach in the wrong place. A C-section can also cause an
intestinal blockage or bladder injury.

A vaginal birth may injure a mom’s pelvic floor muscles. This can cause bladder and bowel control
problems. This may lead to surgery.
Experts don’t agree if this is considered trauma. It may be due to using forceps or vacuum during birth,
how long you push, or the baby’s size. It may also be caused by an episiotomy. This is a cut made to
make the vaginal opening bigger right before birth. Overall, pelvic floor problems are rare enough that
the American College of Obstetricians and Gynecologists says that vaginal births are safer than C-
sections.

Pathophysiology

At the beginning of NSD, mother experiences contractions at regular intervals. Each contraction pushes
the cervix to open. When the cervix is fully dilated, the presenting part of fetus emerges and then comes
out through the birth canal.

Placental Abruption

Placental abruption means the placenta has detached from the wall of the uterus, either partly or totally.
This can cause bleeding in the mother and may interfere with the baby’s supply of oxygen and nutrients.
The cause is unknown in most cases, but risk factors may include maternal high blood pressure,
abdominal trauma and substance misuse. Without prompt medical treatment, a severe case of placental
abruption can have dire consequences for the mother and her unborn child, including death.

Uterine Rupture

A uterine rupture can allow a part of the fetus, amniotic fluid, or the umbilical cord to enter the
peritoneal cavity or broad ligament. A uterine rupture can cause abdominal pain, vaginal bleeding, a
change in the contraction pattern, or a nonreassuring fetal heart rate tracing.

Postpartum Hemorrhage

Postpartum hemorrhage is excessive bleeding following the birth of a baby. About 1 to 5 percent of
women have postpartum hemorrhage and it is more likely with a cesarean birth. Hemorrhage most
commonly occurs after the placenta is delivered
Endometritis

Postpartum endometritis is an infection of the lining of the womb which can occur up to six weeks after
childbirth. It is much more common after caesarean section births. It usually causes a temperature,
tummy pain and heavier vaginal bleeding. Postpartum endometritis needs prompt treatment with
antibiotics

Amniotic Fluid Embolism

Amniotic fluid embolism usually manifests during and shortly after labor and delivery. The first sign may
be sudden cardiac arrest. Other patients suddenly develop dyspnea and have tachycardia, tachypnea,
and hypotension. Respiratory failure, with significant cyanosis, hypoxia and pulmonary crackles, often
quickly follows.
 Laboratory Result

HEMATOLOGY

Hematology is the branch of medicine concerning the study of blood, the blood-forming organs, and

blood diseases. Hematology tests include laboratory assessments of blood formation and blood

disorders.

Full blood count – A count of the total number of red blood cells, white blood cells and platelets present

in blood.

Blood film – Blood is smeared over a glass slide that is stained with specific dyes and viewed under a

microscope. The number, shape and size of blood cells and the presence of any abnormal cells or

immature cells are noted. The stain used for reticulocytes or immature red blood cells is Heilmeyer’s

reticulocyte stain. Staining may flag up abnormally shaped red blood cells such as sickle cells or

spherocytes.

Components Results Normal Value Interpretation Nursing

Responsibilities

Hemoglobin 102 g/L 120-140 g/L Decreased Health Teaching

White blood cells 8.80 10^g/L 5.00-10.00 Normal Health Teaching

Lymphocytes 0.30 0.25-0.35 Normal Health Teaching

Eosinophils 0.04 0.03-0.06 Normal Health Teaching

Monocytes 7% 3.0-12.0 Normal Health Teaching

Hematocrit 0.33 0.37-0.47 Decreased Health Teaching

Platelet count 480 10^9L 140-440 Increased Health Teaching

 URINALYSIS

A urinalysis is a test of your urine. It’s used to detect and manage a wide range of disorders, such as

urinary tract infections, kidney disease and diabetes.

A urinalysis involves checking the appearance, concentration and content of urine. For example, a

urinary tract infection can make urine look cloudy instead of clear. Increased levels of protein in urine

can be a sign of kidney disease.

Components Results Normal Value Interpretation Nursing

responsibilities

Light Yellow
Color Light Yellow Yellow Normal Health Teaching

Specific Gravity 1.005 1.01- 1.030 Normal Health Teaching

Transparency Clear Clear or Cloudy Normal Health Teaching

Sugar Negative Negative Normal Health Teaching

Albumin Negative Negative Normal Health Teaching

Pus Cells 0-2/HPF 0-5/HPF Decreased Health Teaching

RBC 0-2/HPF 0-5/HPF Decreased Health Teaching

Epithelial Cells Few /HPF Decreased Health Teaching

List of Drugs:

• Amoxicillin 5mg tab, 1tab TID x 5 days

• Ascorbic Acid tab, 1tab OD

• Ferrous Sulfate tablet, 1tab OD

4. Mefenamic Acid 5mg tablet, 1tab TID x 3days PRN for pain
 Prognosis

Prognosis Good Fair Poor Justification

-Patient
experience labor
Onset Of Illness ✓ pain a few hours
prior to
admission. She
suffers the first
stage of labor
which is the
dilation of the
cervix. She suffers
pain but She does
some walking and
rubbing of the
back to relieve the
pain. When she
went to the
hospital , the pain
continuous but it
stops sometimes.

-Patient suffered
labor pain every2-
Duration of illness ✓ 3 minustes., she
can tolerate the
pain with the use
of depth
breathing exercise
after the
contraction to
ease the pain.
-Patient can do
personal hygiene
Hygiene ✓ without any
support from
family members
because she is not
really weak.
 -Patient how to
balance diet, she
Diet ✓ have her meal on
time. She usually
eat fruits and
drinking water.
-Patient is a 30
years old and she
Age ✓ is on 3rd time of
delivery. She don’t
have any
complication felt
during pregnancy
but only pain
prior to
admission.
-Patient can stand
up and walk but
Performance ✓ with assistance
Level because she has
not totally
recovered yet
from after giving
birth.
-Patient shows
Willingness to willingness to
Undergo ✓ undergo
treatment treatment for the
reason that she
wants to have a
fast recovery by
having an
adequate rest and
follows prescribed
medicines. She
noted all the
instructions of the
doctor that to
take a rest to
regain strength.
-Families gaves
their full support
Family Support ✓ to our patient
from onset of
labor, during
delivery and
during treatment.
They provide
 patient’s needs in
terms of foods
and clothes. They
always at the
patient side to
attain the needs
of the patient.

7/8 1/8 0/8

GOOD- 7/8 x 100= 87.5

FAIR- 1/8 x 100= 12.5

POOR- 0/8 x 100 = 0

Remarks:

Prognosis shows, the patient condition in getting well is good, because most of the criteria have

good remarks. In this prognosis the pt will recover faster and regain her strength in short duration of

time, with the full support of her family. And because of the patient willingness to recover and eating on

time
References:

E. Cirino, 2017. What is spontaneous vaginal delivery?

https://www.healthline.com/health/pregnancy/spontaneous-vaginal-
delivery#:~:text=A%20spontaneous%20vaginal%20delivery%20is,pregnant%20woman%20goes%20throu
gh%20labor.

NYE Partners in Women’s Health, 2007.NSVD.

https://nyepartners.com/nsvdserv/#:~:text=When%20a%20woman%20goes%20into,spontaneous%20va
ginal%20delivery%20(NSVD).

D. A. Patterson,MD; M. Winslow,MD; C. D. Matus MD, 2018. Spontaneous Vaginal Delivery.

https://www.aafp.org/pubs/afp/issues/2008/0801/p336.html

NHS, 2023. Signs that labor has begun.

https://www.nhs.uk/pregnancy/labour-and-birth/signs-of-labour/signs-that-labour-has-begun/

Thinh Phu Nguyen, MD, 2022. Prenatal Tests: Third Trimester.

https://kidshealth.org/en/parents/tests-third-
trimester.html#:~:text=You%20can%20expect%20to%20get,(dangerously%20high%20blood%20pressure
)

Erica Cirino, 2017. What is a Spontaneous Vaginal Delivery.

https://www.healthline.com/health/pregnancy/spontaneous-vaginal-delivery

Raul Artal-Mittelmark , MD, 2022. Management of Normal Labor.

https://www.msdmanuals.com/professional/gynecology-and-obstetrics/normal-labor-and-
delivery/management-of-normal-
labor#:~:text=For%20spontaneous%20delivery%2C%20women%20must,monitored%20by%20palpation
%20or%20electronically.

LEE T. DRESANG, MD, AND NICOLE YONKE, MD, MPH, 2015. Management of Spontaneous Vaginal
Delivery.

https://www.aafp.org/pubs/afp/issues/2015/0801/p202.html
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https://www.nationwidechildrens.org/family-resources-education/family-resources-library/cesarean-vs-
vaginal-birth-whats-better-for-you-and-your-
baby#:~:text=For%20most%20women%2C%20a%20vaginal,of%20needing%20a%20blood%20transfusio
n

Union Hospital, 2023.Normal Spontaneous Delivery.

https://www.google.com/url?sa=t&source=web&rct=j&opi=89978449&url=https://www.unionwomanca
re.org/pdf/ONG-
09e.pdf&ved=2ahUKEwizwLa9rPKCAxV4aGwGHT7pBZQQFigAegQIDBAA&usg=AOvVaw3a0p7-
brYAuH_6okn89OoO

Better Health Channel, 2014. Placental Abruption.

https://www.betterhealth.vic.gov.au/health/healthyliving/placental-abruption

Brandon M. Togioka; Tiffany Tonismae, 2023. Uterine Rupture.

https://www.ncbi.nlm.nih.gov/books/NBK559209/#:~:text=A%20uterine%20rupture%20can%20allow,no
nreassuring%20fetal%20heart%20rate%20tracing

Children’s Hospital of Philadelphia, 2022. Postpartum Hemorrhage.

https://www.chop.edu/conditions-diseases/postpartum-
hemorrhage#:~:text=Postpartum%20hemorrhage%20is%20excessive%20bleeding,after%20the%20place
nta%20is%20delivered.

Dr Hayley Willacy, 2020. Postpartum Endometritis.

https://patient.info/pregnancy/postpartum-endometritis-
leaflet#:~:text=Postpartum%20endometritis%20is%20an%20infection,needs%20prompt%20treatment%
20with%20antibiotics.

Julie S. Moldenhauer , MD, 2022. Amniotic Fluid Embolism.

https://www.msdmanuals.com/professional/gynecology-and-obstetrics/abnormalities-and-
complications-of-labor-and-delivery/amniotic-fluid-
embolism#:~:text=Amniotic%20fluid%20embolism%20usually%20manifests,Respiratory%20failur