A CASE STUDY OF

NORMAL SPONTANEOUS
VAGINAL DELIVERY
(NSVD)
Presented by: Zhantanna K Andrea Y.
Velasquez
Paul Alfred C. Pantinople II
Rachelle Khylle A. Salar
Gwyn Surdee L. Pajo
Aloah Mae O. Oragis
Kharena D. Pugahan
Sharmaine D. Pural
Lindley C. Tipon
Junah K. Pelayo
Kent Jeriel Tan
 INTRODUCTION
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. (Cirino, E., 2017.)

The researchers chose this case because it is interesting

for us knowing that the patient is experiencing teenage pregnancy and it is also
her first-time giving birth. With that being said, the researchers would want to
know the physical and physiological effects to the body of having birth at such a
very young age. Furthermore, the researchers hope to increase knowledge
regarding a patient diagnosed with a Normal Spontaneous Delivery (NSVD).
BACKGROUND OF THE STUDY
The patient in this study is a 16-year-old female named
Ms. E, and was brought to the hospital with pregnancy uterine of 35 4/7
weeks age of Gestation whilst baby is in cephalic presentation. 17 hours
PTA, patient was noted of experiencing labor pains associated with regular
contractions, active fetal movement, and having no vaginal bleeding and
watery discharge.
During labor, patient had live birth in cephalic
presentation with baby boy having APGAR score of 8,9; Birthweight 2340
grams, Ballard score of 35 weeks delivered via normal spontaneous vaginal
delivery with third degree laceration.
Upon admission, patient’s physical examination
was done and the results were: awake, coherent, not in respiratory distress,
anicteric sclerae, pink palpebral conjunctiva, equal chest expansion, clear
breath sounds, adynamic precordium, distinct heart sounds, and no edema.
Specifically, pelvic examination showed the following: normal external
genitalia, smooth vaginal canal, 5 cm dilation, 50 percent effacement, and
having adequate clinical pelvimetry.
SIGNIFICANCE OF THE STUDY
This study is deemed to be extremely valuable to the future researchers, the school, the
community, and the student nurses who will gain knowledge from it. The following are the
reasons the group thinks this study is crucial:
 
to the student nurses: the researchers want to underline the importance of this
research on the specific Normal Delivery and its indications of delivery, in order to better
understand how NSVD is being performed and how it can be managed through nursing
care.
 
to the students: their knowledge and understanding of this topic will grow as a result
of the study's information gathering, which will provide them with more details about
normal spontaneous vaginal delivery.
 
to the community: The information provided will raise community understanding and
awareness of normal spontaneous vaginal delivery and help members to develop
initiatives or preventative measures to decrease.
 
to the future researchers: To the future researchers: this study would be used as a
guide in order for them to have explicit, clear, and practical suggestions for future
researchers in doing a research study similar to this one.
 DEFINITION OF TERMS
Normal Spontaneous Vaginal Delivery (NSVD), A normal 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. (Cirino, 2017)
Median Episiotomy, A vertical incision is made along the midline. An
incision in the middle is simpler to fix. But there is a greater chance that it
will spread to the anal region. (Berkowitz, 2018)
 RELATED LITERATURE
1.) A holistic, comprehensive antenatal, and preventive program should be
conducted to prevent teenage pregnancy-related adverse outcomes. (UNICEF,
“Young people and family planning: teenage pregnancy,” 2015)

2.) Further research is warranted to determine the role of prenatal pelvic floor
(Kegel) exercises, general exercise, and body mass index in reducing obstetric
trauma, and also the role of pelvic floor and general exercise in pelvic floor
recovery after childbirth. (Department of Obstetrics and Gynecology, School of
Medicine at the University of New Mexico Health Sciences, 2019)

3.) The strongest factor associated with episiotomy at delivery was the category of
obstetric provider. (Journal de Gynecologie Obstetrique et Biologie de la
Reproduction, 2020)

4.) Our data suggest that in forceps delivery neither the type of forceps nor
episiotomy influences the risk of significant perineal trauma. When vacuum
extraction delivery is performed, the use of episiotomy is associated with a higher
risk of significant perineal trauma. (European Journal of Obstetrics and
Gynecology and Reproductive Biology, 2020)
 EVIDENCE BASE
● The episiotomy procedure per se and the type of
episiotomy as well as birth weight, assisted vaginal delivery, and older
maternal age were identified as independent risk factors associated with third-
and fourth-degree perineal lacerations. (Angioli, R., Gómez-Marín, O.,
Cantuaria, G., & O’Sullivan, M. J., 2000.)
● When analyzing the probability for third-degree perineal tears, a strong
association with primiparity (p = 0.01), the use of episiotomy (p = 0.0001), a
prolonged second stage of labor (p = 0.0001), a large head diameter of the
infant (p = 0.01) and the use of oxytocin (p = 0.008) was found. (Bodner, K.,
Bodner-Adler, B., Wagenbichler, P., Kaider, A., Leodolter, S., Husslein, P., &
Mayerhofer, K., 2001.)
● For all mothers, delivery of the infant's head between contractions was
associated with reduced trauma to the genital tract. (Albers, L. L., Sedler, K.
D., Bedrick, E. J., Teaf, D., & Peralta, P., 2006.)
ANATOMY AND PHYSIOLOGY
INVLOVED
The Female Reproductive System
Anatomy of the female reproductive system. The organs in the female reproductive
system include the uterus, ovaries, fallopian tubes, cervix, and vagina. The uterus has a
muscular outer layer called the myometrium and an inner lining called the endometrium.
 
 
 
Vagina
The uterus, where the embryo develops into a fetus during pregnancy, is connected to
the external genitals by the vagina, a muscular, ridged sheath.
Cervix
It is a passage that allows fluids to flow inside and out of the uterus. It's also a
powerful gatekeeper that can open and close in ways that make pregnancy and childbirth
possible.
Uterus
The uterus or womb is the major female reproductive organ of humans It’s major
function is to accept a fertilized ovum which becomes implanted into the endometrium,
and derives nourishment from blood vessels which develop exclusively for this purpose.
The uterus has a muscular outer layer called the myometrium and an inner lining called
the endometrium.
Oviducts
Fallopian tubes or oviducts are two very fine tubes leading from the ovaries of
female mammals into the uterus.
Ovaries
The ovaries are place inside the female body where ova or eggs are produced.
The process by which the ovum is released is called ovulation.
 COLLECTION
PROCEDURE/METHOD AND
SOURCES OF INFORMATION
Ms. E’s condition, profile, and other necessary details
were collected from secondary source which is the hospital nurse. Medical record
of the patient was also presented to the researchers. Other information was
obtained through personal interview and rest assured that researchers asked for
permission to obtain the data.
 
 DEVELOPMENTAL STAGES: IDENTIFY
PRIORITY NEEDS AND DEPRIVATION
Erick Erickson’s theory of Psychosocial Growth and Development
 
According to McLeod (2018), From infancy to maturity, Erikson
argued that personality develops throughout eight stages of psychosocial
development in a specified order.

Sigmund Freud’s Theory of Psychosexual Growth and Development

Freud proposed that personality development in childhood takes
place during five psychosexual stages, which are the oral, anal, phallic,
latency, and genital stages.
PROBLEM LIST

Acute vaginal pain related to median

episiotomy as evidenced by
discomfort while moving and walking
Risk for uterine infection related to
episiotomy
 Nursing Diagnosis
1.) Ineffective Breastfeeding related to poor sucking reflex of infant as
evidenced by failure to latch.
2.) Ineffective Breastfeeding related to poor sucking reflex of infant as
evidenced by failure to latch.
3.) Risk for uterine infection related to episiotomy
4.) Acute vaginal pain related to right median episiotomy as evidenced by
discomfort while moving and walking.
Setting Goals and Objectives
1.)After 8 hours of nursing care, the patient will implement two techniques to
improve breastfeeding.
2.)After 8 hours of nursing care, the client will able to demonstrate parenting
roles with confidence.
3.)After 8 hours of nursing care, the client will be able to verbalize
understanding of risk factors and identify interventions and demonstrate
techniques to prevent risk of infection.
4.)After 30 minutes of rendering nursing intervention, the patient will be able
to verbalized comfort and pain relief through speech, and the patient will
interact in desired activities without having experienced more pain.

 
 DEVELOPMENTAL STAGES: IDENTIFY
APPLICATION OF STANDARDS OF NURSING
PRACTICE (11 KEY AREAS OF NURSING
RESPONSIBILITY)
1. Safe and Quality Nursing Care
2. Management of Resources and Environment
3. Health Education
4. Legal Responsibility
5. Ethico-Moral Responsibility
6. Personal and Professional Development
7. Quality Improvement
8. Research
9. Record Management
10. Communication
11. Collaboration and Teamwork
 HEALTH EDUCATION:
INSTRUCTION AND PROMOTION
● Primary prevention
OF HEALTH
Primary prevention includes the promotion of Department of Education to implement age and development-
appropriate Comprehensive Sexuality Education (CSE) in formal and non-formal education settings;
Correct use of contraceptives method.
The effectiveness of sexual education programs.
 
● Secondary prevention
Involves programs like Adolescent Health and Development Program (AHDP) that targets adolescents aged 10-19
years. It is mainly guided by the Convention on the Rights of Children. Based on the Department of Health (DOH)
Administrative Order (AO) 2013-0013 or the National Policy and Strategic Framework on Adolescent Health and
Development Administrative Order, the program primarily aims to provide adolescents access to quality healthcare
services. This means increased accessibility of adolescent-friendly facilities, programs, and health providers for the
Filipino youth.
● Tertiary prevention
Tertiary prevention includes the integration and institutionalization of “The National Safe Motherhood Program”,
which primarily focuses on the health and welfare of women throughout their pregnancy. It also includes the
adolescent pregnant and meeting the unmet needs for family planning contraceptives of women into its priority
agenda until 2030. This program aims to provide Filipino women access to quality healthcare for a safer pregnancy
and delivery. It aims to promote the health and well-being of mothers of a Filipino family.
 DISCHARGE PLAN
Medication
Instruct client to follow and take medications prescribed by the physician.
Explain to the client the nature of the drugs so as the prescription.
Environment:
Stay in a conducive environment to prevent too much stress and get some
rest when the baby is asleep.
Make sure that your room is clean and eliminate breeding sites of vectors of
diseases.
Be surrounded with family and friends for support and prevent postpartum
depression.
 Treatment:
Continue home medication.
For the follow-up check-up repeat.
Encourage patient to take multivitamins and have a balanced diet.
Create a safe and supportive environment.
 
 HEALTH EDUCATION:
INSTRUCTION AND PROMOTION
OF HEALTH
Health Teaching:
Get plenty of rest. Get as much sleep as possible to cope with tiredness and fatigue.
● Seek help. Don’t hesitate to accept help from family and friends during the postpartum period, as well as after
this period. The body needs to heal, and practical help around the home can help you get much-needed rest.
Friends or family can prepare meals, run errands, or help care for other children in the home.
● Exercise, doctor will let you know when it’s allowed to exercise. The activity should not be strenuous. Try taking
a walk near your house. The change of scenery is refreshing and can increase your energy level.
● Take showers instead of tub baths. This helps prevent infection.
● Use sanitary pads as needed. You may have light bleeding or spotting for 2 weeks.
● Advice client to do proper perineal care regularly.
● Adhere to the chosen family planning and birth control pills as prescribed by physician.
Outpatient Referral:
● The patient should attend his follow-up check-up in order for the physician to see his progress of the patient and
to advise him what to do.
Diet:
● Eat healthy meals. Maintain a healthy diet to promote healing. Increase intake of whole grains, vegetables, fruits,
and protein. You should also increase your fluid intake, especially if you are breast-feeding.

 
 EVALUATION AND MODIFICATION
The group was able to come up with the understanding with the case
presented about a patient who undergone Normal Spontaneous Vaginal
Delivery (NSVD).
1. After the case study objective were met. We are able to:
Identify our patient.
2. Establish a trusting relationship with the patient, family, and significant
others.
3. Gather enough information regarding the patient, her family background.
4. Present significance of the study for the students, and more emphasis on
the nursing education to the patient and family.
5. Present selected terms related to the study.
6. Gather review of related literature that would address and emphasize the
importance of the disease to be tackled with evidence-based practice.
7. Discuss the anatomy and physiology of the organ and systems involve in
the condition.
Identify the precipitating and predisposing factor as a basis in the
formulation of pathophysiology.
 
8 Identify the precipitating and predisposing factor as a basis in the
formulation of pathophysiology.
9. Determine the etiology and symptomology.
10. Trace the pathophysiology of incomplete abortion related to the case.
11. Determine the health history with past and history of present illness
including genogram.
12. Identify the drugs prescribed for the patient’s condition.
13. Present the laboratory results and discussed its significance
14.Provide good medical prognosis with justification as evidence by
computation
15.Present the nursing theories applicable to the patient’s condition.
16.Formulate effective nursing care plan to address the identified problem.
17Give health teaching as well as discharge plan for the patient’s progress
and recovery.
18. Provide conclusion and recommendation for the prevention regarding
the patient’s condition.