Presented by:

Sanchez, Hennie Vee G.

Maldo, Micah Joyce P.
BSN- II LEVINE
INTRODUCTION

A case of a 25-year-old woman, Mrs. B who was brought to the hospital by her
mother in law and reports that she has been in labor for 8 hours and that her
membranes ruptured 3 hours ago. Upon arrival at the hospital, she had a strong
contraction lasting 45 seconds and is showing signs of labor. A quick check to
detect signs/symptoms of life-threatening complications have been completed
and, finding none, quickly proceeded to physical examination to determine
whether birth is imminent. Although Mrs. B is not pushing, and has a bulging, thin
perineum.
EPIDEMIOLOGY

Normal labor is defined as the gradual subjugation and dilatation of the uterine
cervix as a result of rhythmic uterine contractions leading to the expulsion of the
products of conception: the delivery of the fetus, membranes, umbilical cord,
and placenta. Laboring cannot that be easy; thereby implicating that there are
processes and stages to be undertaken to achieve spontaneous delivery. Through
which, Obstetrics have divided labor into four (4) stages thereby explaining this
continuous process.
General Objectives:

This study aimed to broaden the student’s knowledge for Normal Spontaneous
Vaginal Delivery by obtaining sufficient information which could serve as a guide
for student nurses who will be focusing on the same case and it is also designed
to enhance skills and attitudes in the application of nursing process and
management of the procedure.
Specific Objectives:

After thoroughly discussed the case presented, the nursing students shall be able to:
• To gain enough knowledge and understand the entire course of the procedure.
• To know the client’s personal data, her family profile, past health history,
current medical history, and physical assessment.
• To review the anatomy and physiology of the female reproductive system.
• To discuss the purpose of the procedure and its possible complication.
• To correlate the results of the diagnostic procedures to its normal values.
• To develop an effective nursing care plan in which the client may benefit
Questions:

1. What history will you include in your assessment of Mrs. B and why?
- Past obstetric history. It is important to know how many pregnancies the patient has
gone through/lost. Patients often forget about miscarriages and ectopic pregnancies,
and may also not mention previous pregnancies from another husband or boyfriend.
Mrs. B.’s antenatal records should be quickly checked for history of present
pregnancy, as well as obstetric and medical histories, with particular attention to
problems and treatments
2. What physical examination will you include in your assessment of Mrs. B and why?
-You should perform the following elements of examination to guide further
assessment and help individualize care provision. Some findings may help determine
stage/phase of labor, or may indicate a special need/condition that requires
additional care or a life- threatening complication that requires immediate attention
-Mrs. B.’s respirations, blood pressure, temperature and pulse should be measured to ensure
normalcy/normal progress, and detect abnormal signs/symptoms.
Abdominal examination including assessment of:
- Surface of abdomen for presence of scars, which might indicate a previous C-section or other uterine
surgery
- Uterine shape, which may indicate lie and/or uterine abnormality
- Fundal height, which will helps confirm gestational age or indicate size-date discrepancy
- Fetal parts and movement,which may indicate multiple pregnancy
3. What laboratory tests will you include in your assessment of Mrs. B and why?
- A urinalysis and a CBC test because urinalysis is important to rule out a urinary tract infection.
Pregnant women are prone to urinary tract infections due to the progesterone effect on the smooth
muscle of the ureters and a complete blood count to identify and prevent problems, a CBC may be done
before pregnancy, if possible, at the beginning of pregnancy, and one or more times during pregnancy.
The first baseline results can be compared to later values to look for changes that could indicate a health
issue.
4. Based on these findings, what is Mrs. X's diagnosis (problem/need) and why?
- Mrs. B. has reached the second stage of labor, indicated by full dilation of the cervix
5. Based on your diagnosis (problem/need identification), what is your plan of care for Mrs. B and why?
- Mrs. B. must not be left alone. She should receive on going assessment (e.g., maternal pulse and
contractions every30 minutes, fetal heartrate every 5minutes) to ensure that any problems or abnormalities
in the condition of mother or baby or progress of labor are detected early for immediate attention.
She should receive on going supportive care:
 A supportive, encouraging atmosphere that is respectful of Mrs. B’s wishes should be established to provide
emotional support.
 Mrs. B. should be made comfortable and encouraged to adopt a position for pushing that is comfortable for
her and aids in the descent of the fetus: semi-sitting/reclining, squatting, hands and knees or lying on side.
 Mrs. B. should been courage to follow her own tendency to push: the intensity of her contractions should
regulate her efforts to push. She should be encouraged not to
6. Based on these findings, what is your continuing plan of care for Mrs. B and why?
Immediate new born care should be provided:
 Thoroughly dry baby and cover in clean, warm cloth.
 Clamp/tie and cut cord.
 Place baby in skin-to-skin contact on the mother's abdomen; encourage breastfeeding.
 Once Mrs. B.’s abdomen is palpated to rule out the presence of an additional baby, the placenta should be delivered using active
management of third stage of labor:
  Administer oxytocin 10 units IM.
  Perform controlled cord traction.
  Deliver and examine the placenta
 Placenta, cord, and membranes should be checked for completeness.
  Assess uterine tone and if necessary massage the uterus through the abdomen until firmly contracted (Mrs. B. should also be shown how to
massage her fundus to maintain the contraction)
  Examine the vagina and perineum for lacerations or tears.
  Mrs. B. should be made comfortable (e.g., cleanse perineum, change bed linens).
  She and the baby should receive ongoing assessment every 15minutes for first 2 hours following birth (e.g., mother: blood pressure, pulse,
fundus [for firmness], and vaginal bleeding; newborn: respiration, warmth, color to ensure that any problems or abnormalities in the
condition of mother or baby are detected early for immediate attention
NURSING HEALTH HISTORY

 A. Biographic Data
 Name: Mrs. B
 Address: N/A
 Age: 25
 Gender: Female
 Marital Status: Married
 Occupation: N/A
 Religious Orientation: N/A
 Health Care Financing: N/A
 Informant:
B. Chief Complaint:

Few hours prior to admission on the hospital the patient was already in labor for
8 hours that her membranes ruptured 3 hours ago. Upon arrival she was assessed
with bulging in her perineum
C. History of Present Illness:

N/A
D. Past History

The patient has no known allergy to any foods or drugs and has no history of
hypertension, diabetes mellitus or asthma
E. Family History

There was no known familial disease in their family

GORDON’S FUNCTIONAL HEALTH PATTERN

A. Health Perception and Health Maintenance Management Pattern

Patient is 25 yrs. Old, female and married. She was in labor for 8 hours and that
her membranes ruptures 3 hours ago before she was admitted in to the hospital.
She had a strong contraction lasting for 45 seconds and there is a bulging in her
perineum which is possibly cause by the pressure during her prolonged labor
B. Nutritional & Metabolic Pattern
Patient has complete meals (breakfast, lunch, and dinner) and has fluid intake of
8-10 glasses /day. She eats meats, vegetables and fruits.
C. Elimination Pattern
Bladder Habits:
She can void 3 to 4x a day without any pain felt
Bowel Habits:
She can defecate once a day with a formed stool
D. Activity-Exercise Pattern
During pregnancy the patient do exercise which can reduce backaches,
constipation, bloating and swelling. Boost your mood and energy levels. Help you
sleep better.
E. Sleep-Rest Pattern
She has a good sleep-wake cycle. She usually sleeps 6-8 hours
F. Cognitive-Perceptual Pattern
She has no deficit in her sensory perception (hearing and sight) and she’s able to read and
write. She can hear and answer questions being asked. She is aware of the conversation.
She can see people that surrounds her.
G. Self-Perception and Self-Concept Pattern
According to her significant others, patient is a good mother and daughter. She is not a
smoker and doesn’t drink. She wants to reach her goals later on.
H. Role relationship pattern
Patient is very responsible. She always said that she wants to attain her goals or dreams
for her family
I. Sexually-reproductive pattern
Patient experienced sexual intercourse
J. Coping stress pattern
She said that, whenever she has a problem she shares it to the family and solve
the problems by herself and of course, listens to the advices of her family
K. Value-belief pattern
She is a roman catholic. She attended masses together with the family every
Sunday.
DEFINITION OF TERMS

1.
Normal Spontaneous Vaginal Delivery (NSVD)
A normal spontaneous vaginal delivery (NSVD) occurs when a pregnant female goes into labor without the use of drugs or techniques
to induce labor, and delivers her baby in the normal manner, without forceps, vacuum extraction, or a cesarean section.
 
2.
Normal Spontaneous Vaginal Delivery (NSVD)
Vaginal delivery is the method of childbirth most health experts recommend for women whose babies have reached full term.
Compared to other methods of childbirth, such as a cesarean delivery and induced labor, it’s the simplest kind of delivery process. 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.
 
3.
Normal Spontaneous Vaginal Delivery (NSVD)
Normal spontaneous vaginal delivery 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 is known
as a normal spontaneous vaginal delivery (NSVD).
ANATOMY AND PHYSIOLOGY

During labor, the role of the cervix must change from maintaining the pregnancy
(by keeping the uterus closed) to facilitating delivery of the baby (by dilating, or
opening, enough to allow the baby through). The fundamental changes that occur
near the end of the pregnancy result in a softening of the cervical tissue and
thinning of the cervix, both of which help prepare the cervix. True, active labor is
considered to be underway when the cervix is dilated 3 centimeters or more.
Eventually, the cervical canal must open until the cervical opening itself has
reached 10 centimeters in diameter and the baby is able to pass into the birth
canal. As the baby enters the vagina, your skin and muscles stretch. The labia and
perineum (the area between the vagina and the rectum) eventually reach a point
of maximum stretching. At this point, the skin may feel like it’s burning. Some
childbirth educators call this the ring of fire because of the burning sensation felt
as the mother’s tissues stretch around the baby’s head. At this time, your
healthcare provider may decide to perform an episiotomy
MEDICAL MANAGEMENT
DRUG STUDY
NURSING CARE PLAN
HEALTH TEACHING PLAN
DISCHARGE PLAN
 JOURNAL READING 1
 
An audit of external cephalic version procedures at Kings College Hospital
Rehal A , Datta S
Kings College Hospital, London, UK
Objectives
External cephalic version (ECV) is a method commonly used to manipulate the fetus abdominally to a cephalic presentation. The purpose of this
audit was to evaluate all ECV procedures over a one‐year period in our unit, to analyse subsequent pregnancy outcomes and compare these with
previous audits.
Design
This was a retrospective audit, analysing all ECV procedures performed in the year 2017.
Methods
Data queries were used to extract all patients with a non‐cephalic fetus at the routine 36 weeks’ scan, and a second query extracted all breech
deliveries.
Results
250 fetuses were breech at the routine 36 weeks’ scan. From these, 110 ECV procedures were attempted. 34.6% were successful and 86% of these
patients had a vaginal delivery. From those procedures that failed, all patients delivered by caesarean section. A greater success rate was seen in
multiparous compared with nulliparous patients (51% versus 26%). When compared with the results from previous audits, there had been an overall
increase in ECV procedures; however, the success rate had fallen compared to the previous year.
Conclusion
The results show that antenatal detection of breech presentation is extremely high in our unit and can be explained by the routine 36 weeks’ scan.
ECV remains one of the principal methods to reduce the incidence of breech presentation, thereby potentially avoiding caesarean section and its
sequelae. Further audit would need to be carried out looking at the factors associated with failure in terms of case selection and operator
experience.
JOURNAL READING 2

Sphincter Injury
By: Marta Simó González

Obstetric anal sphincter injury encompasses third and fourth degree perineal tearing that occurs during
delivery, according to Sultan’s classification. This classification considers perineal injuries as a 3rd degree tear when there
is any involvement of the anal sphincter and 4th degree tear when the anal epithelium is involved. This classification is
incorporated in the RCOG guidelines and included in the Green Top Guidelines for the Management of Third and Fourth-
Degree Perineal Tears Following Vaginal Delivery. Third degree tears are further classified into three subgroups according
to the extent of damage to the external anal sphincter and internal anal sphincter. The incidence of obstetric anal
sphincter injury varies between 0.5 and 5% of vaginal deliveries and it is the most common cause of anal incontinence in
healthy women [3]. Obstetric anal sphincter injury is a serious complication of childbirth due to its notable maternal
morbidity, its serious physical and emotional effects, and its impact on quality of life. Awareness of the factors most
frequently associated with this injury is essential and can help obstetricians perform safer deliveries for both mother and
child. A total of 4526 vaginal births were recorded during the study period. Obstetric anal sphincter injury occurred in 97
cases, giving an incidence of 2.14% (CI 95% = 1.72–2.57).

Source: https://www.hindawi.com/journals/ogi/2015/679470/
 EVALUATION AND IMPLICATION TO:

1. Nursing Practice
Knowledge, skills and attitude should always be present on the practice of the nursing profession. In carrying
out the nursing actions & interventions, the underlying principles and standards must always be observed to
provide total patient care. The nursing care plans in this presentation will aid the learners in the care of the
patients.

2. Nursing Education
This presentation will help future students gain knowledge about the case –Spontaneous Vaginal Delivery. This
case presentation will also encourage health teaching to caregivers and other health care professionals.

3. Nursing Research
In the field of research, this case presentation will encourage effective therapeutic management for patients
undergoing normal spontaneous vaginal delivery. It will also give more insights to future researchers about the
normal spontaneous vaginal delivery and its nursing management.