FATHER SATURNINO URIOS UNIVERSITY

Butuan City
Nursing Program

A CASE STUDY
ON
NORMAL SPONTANEOUS VAGINAL
DELIVERY

BUTUAN MEDICAL CENTER

(Ob-Nursery Ward)
June 13, 2008 – July 12, 2008

In partial fulfillment
Of the requirements for the
Subject NCM 101

Submitted by:
Florence Phil H. Amoroso
BSN – III

Submitted to:
Mr. Paul Ritchie Pelos, RN
Clinical Instructor
 INTRODUCTION

Pregnancy, the state of carrying a developing embryo or fetus

within the female body. This condition can be indicated by positive results

on an over-the-counter urine test, and confirmed through a blood test,

ultrasound, detection of fetal heartbeat, or an X-ray. Pregnancy lasts for

about nine months, measured from the date of the woman's last

menstrual period (LMP). It is conventionally divided into three trimesters,

each roughly three months long.

When gestation has completed, it goes through a process

called delivery, where the developed fetus is expelled from the mother’s

womb. There are two options of delivery: Cesarean section and NSVD or

normal spontaneous vaginal delivery. A cesarean section is a surgical

incision through the mother’s abdomen and uterus to deliver one or more

fetuses. NSVD or normal spontaneous vaginal delivery is the delivery of

the baby through vaginal route. It can also be called NSD or normal

spontaneous delivery, or SVD or spontaneous vaginal delivery, where the

mother delivers the baby with effort and force exertion.

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.
 STAGE 1: It is usually the longest part of labor. It begins with

regular uterine contractions and ends with complete cervical dilatation at

10 centimeters. This stage is broken down into three (3) phases: the Early

phase, where the contractions are usually very light and maybe

approximately 20 minutes or more apart from the beginning, gradually

becoming closer, possibly up to five minutes apart; the Active phase,

where contractions are generally four or five times apart, and may last up

to 60 seconds long. Cervix dilates with 4-7 cm and initiates a more rapid

dilatation. It is known that to get through active labor, mobility and

relaxations are done to increase contractions; and the Transition phase,

where it is definitely known as the shortest phase but the hardest,

contractions maybe two or three times apart, lasting up to a minute and a

half, about approximately 8-10 cm of cervical dilatation. Some women will

shake and may vomit during this stage, and this is regarded as normal.

Most of the time, women would find a comfortable position to acquire

complete dilatation.

STAGE II: This stage lasts for three or more hours. However,

the length of this stage depends upon the mother’s position (e.g.; upright

position yields faster delivery). Once the cervix has completely dilated,

the second stage had begun. This stage ends with the expulsion of the

fetus.

STAGE III: This stage focuses on the expulsion of the

placenta from the mother. Placenta exclusion is much more easier than

the delivery of the baby because it includes no bones, and this is during

this stage that the baby is placed on top of the mother’s womb.
 STAGE IV: No more expulsions of conception products for this

stage as this is generally accepted as POST PARTUM juncture. This phase

is from the placental delivery to full recovery of the mother.

Labor and delivery of the fetus entails physiological effects

both on the mother and the fetus. In the cardiovascular system, the

mother’s cardiac output increases because of the increase in the needed

amount of blood in the uterine area. Blood pressure may also rise due to

the effort exerted by the mother in order expel the fetus. There could also

be a development of leukocytes or a sharp increase in the number of

circulating white blood cells possibly as a result of stress and heavy

exertion. Increased respiratory may also occur. This happens as a

response to the increase in blood supply in order to increase also the

oxygen intake.

Braxton Hicks contractions, or also known as false labor or practice

contractions. Braxton Hicks are sporadic uterine contractions that

actually start at about 6 weeks, although one will not feel them that early.

Most women start feeling them during the second or third trimester of

pregnancy. True labor is felt in the upper and mid abdomen and leads to

the cervical changes that define true labor.

With delivery imminent, the mother is usually placed supine with

her knees bent (ie, the dorsal lithotomy position). An episiotomy (an

incision continuous with the vaginal introitus) may be performed at this

time. Episiotomy may ease delivery of the fetal head and allow some

control over what may otherwise be an uncontrolled perineal laceration.

However, many providers no longer perform routine episiotomy, since it

may increase the risk of rectal injury and are larger than the spontaneous

laceration.
 The labor and birth process is always accompanied by pain. Several

options for pain control are available, ranging from intramuscular or

intravenous doses of narcotics, such as Meperidine (Demerol), to general

anesthesia. Regional nerve blocks, such as a pudendal block or local

infiltration of the perineal area can also be used. Further options include

epidural blocks and spinal anesthetics.

Nursing Health History

Nursing health history is the first part and one of the most

significant aspects in case studies. It is a systematic collection of

subjective and objective data, ordering and a step-by-step process

inculcating detailed information in determining client’s history, health

status, functional status and coping pattern. These vital informations

provide a conceptual baseline data utilized in developing nursing

diagnosis, subsequent plans for individualized care and for the nursing

process application as a whole.

In keeping the private life of my patient and in maintaining

confidentiality, let me hide for with the pseudonym of Patient P.

Patient P was born on December 19, 1992. She was born to parents

from Surigao Del Norte, but she didn’t actually live with them. She was

technically abandoned to the relatives, but those people could not

essentially foster her. She stayed at the Department of Welfare and Social

Development or DSWD and spent her 15 years of existence. Her

education was funded mainly by volunteers and charitable foundations. At

the same time, she compensated for it by means of helping in chores and

accomplishing tasks in the said foundation.

She grew up with other abandoned children with questions in her

mind. But to that, she never completely disclosed herself. Patient P is a

victim of sexual abuse. She was raped and was unable to resist because

of her innocence. She doesn’t talk that much. Often times, she paces back

and forth inside the ward, sits silently on her bed and sometimes quietly

stares outside the window. When tried to ask about what she knows of her

family, she could only turn silent, and somehow implies to ask the next

question to her. But when chance punched, I grasped it and coiled directly

to my point. Unfortunately, hesitancy was felt from the kind of thing that

was wanted to be discussed. The issue was not forced until her watcher,

which has no relation to her, revealed the reason behind her pregnancy.

According to Patient P’s watcher, it was on a cold night in

September 2007, when Patient P came home from school: Upon nearing

the center, a man, which she identified as a newcomer to the center,

blocked and harassed her brutally. She struggled to let go from the

ruthless hands of the unaccustomed man. Patient P was threatened that if

she’d make any noise, she’d get killed. Ill-fatedly, she was held powerless

to the man, and the crime had happened. Fortunate enough that she

wasn’t killed, she thanked the Lord for sparing her life. Although alive, she

felt very much unfair about her situation. She could only tell, “Kabata pa

kaayo nako nahimong inahan, nganong nahitabo man pud ni..” . Patient P

conceived the baby and bore it for 9 months. For the first trimester, she

couldn’t believe and accept her fate, and sometimes thought of slight

curses to the person who did the crime. But somehow, she felt a jot of

excitement of a having a baby unexpectedly. She even verbalized, “Wa

naman koy mabuhat. Nahitabo nato. Basin makasala pa kog ipalaglag

nako ang bata.. Wala man siya’y sala.”

According to Erik Erikson’s Developmental Task of adolescence,

from the age of 10 to 18 years old, Patient P belonged to the IDENTITY

versus ROLE CONFUSION, which proposes that the adolescent is newly

concerned with how he or she appears to others. Development mostly

depends upon what is done to us. From here on out, development

depends primarily upon what we do. And while adolescence is a stage at

which we are neither a child nor an adult, life is definitely getting more

complex as we attempt to find our own identity, struggle with social

interactions, and grapple with moral issues.

On June 29, 2008, Patient P complained of extreme abdominal pain.

On the same date was her EDC or expected date of confinement. The age

of gestation is 39 weeks by LMP. Her LMP was September 2007, exact

date unrecalled. She was admitted to Butuan Medical Center at around

2:40am with blood pressure of 140/90 mmHg. She was examined by Dr.

Bombeo and found out that she was fully dilated. By 2:45am, 5 minutes

after her admission, doctor’s orders were carried out:

• #1 D5LR I Liter started @ 20 gtts/min

• TPR q 4°

• NPO

• CBC blood typing; hbsAg requested

• Labor watch
 By 2:55am, she was endorsed to DR wheelchair. With the next 5

minutes, she was admitted in the ER accompanied by the staff, positioned

on the DR table with final preparation done.

Around 3:36 am, she delivered an alive, 6 lbs 13 oz and 49

centimeters in length baby girl with these statistics:

• Head Circ: 32 cm

• Chest Circ: 30 cm

• Abd Circ: 20 cm

Extemporaneously, the baby cried with the same breathing time of

3:36am. Patient P’s placenta was expelled spontaneously by 3:47am with

blood pressure of 130/80. Oxytocin 10 units was infused to IVF;

Methergine I amp IVTT; her uterus was firm and contracted and was

admitted to ward via stretcher. During her labor, she was anesthetized

with Lidocaine HCl 5cc.

After her delivery, she was admitted to the Ob ward with repaired

episiotomy. Post partum doctor’s orders were as follows which was carried

out:

• DAT (Diet as Tolerated)

• Ice pack over hypogastrium

• Perineal care

• Oxytocin 10 U infused to IVF and;

• Methergine I amp IVTT.

• Cephalexin I amp IVTT

• Mefenamic Acid 500mg I cap TID

 • May room in

• Breastfeed per demand

Patient P’s temperature was monitored until stable.

On the following day, June 30, 2008, doctor’s order was to secure

HBsAg result. Patient P’s baby was admitted to NICU because of frequent

vomiting and fever. The staff continued to monitor her vital signs and

administered prescribed medications. As a student nurse, I also did my

assessment towards my patient’s condition. Upon assessing, I was able to

take and record her vital signs:

• T = 37.3°c

• 82 bpm

• 21 cpm

• 120/70 mmHg

Patient P wasn’t able to take a bath because of her beliefs. Since

she has an episiotomy wound, she is at risk for infection. I made my

independent nursing interventions. I explained to her the importance of

proper hygiene to prevent the occurrence of infection. Emphasis on eating

foods rich high protein to promote wound healing was imparted. She

verbalized, “Sakit man akong totoy mam.” So, I encouraged her to let her

baby continuously suck to both breasts when received back from NICU,

that is to relieve her engorgement. Also, I instructed her to increase fluid

intake at least 8 oz per hour to facilitate increase in milk production, and

to eat nutritious foods such as fruits and vegetables to nourish her baby

well.
 On July 1, 2008, doctor’s orders were noted:

• Continue meds

• Repeat hemoglobin

• MGH after IE and if hemoglobin is OK

By 1:25 pm:

• Defer MGH

• Secure and transfuse 4 units FWB/wg (fresh whole

blood) properly crossmatched

• Antamine I amp 10,000 units

• BT (blood transfusion)

On the same day, I did my Physical assessment to Patient P and a

brief history about her case. I aided her in securing her blood by

persistently going with her to the blood bank. Patient P was advised to

take adequate rest in fear of hypotension due to her low hemoglobin,

59G/L. So, it was me and her watcher who was always on the go. I

continued to administer her medications per prescription:

• Cephalexin 500mg I cap TID

• Mefenamic Acid 500mg I cap TID

July 2, 2008, doctor’s order was to follow up 4 units of blood. Patient

P was reinserted with IV D5LR.

On July 7, 2008, Patient P was transfused with 4 units of fresh whole

blood, baby was already on mother’s side, and were about to go home.

She was seen with the health workers facilitating her discharge from the

hospital.
 PHYSICAL ASSESSMENT

Physical examination follows a methodical head to toe format in the

Cephalocaudal assessment. This is done systematically using the

techniques of inspection, palpation, percussion and auscultation with the

use of materials and investments such as the penlight, thermometer,

sphygmomanometer, tape measure and stethoscope and also the senses.

During the procedure, I made every effort to recognize and respect the

patient’s feelings as well as to provide comfort measures and follow

appropriate safety precautions.

A. General Physical Assessment

Patient is a 15 year old female, stands 5’4, with pulse rate of 82

beats pre minute, respiratory rate of 21 breathe per minute and a

temperature of 37.3 °C. She is conscious and coherent upon interaction

but answers only the questions she is comfortable with. Most of the time,

she is pacing inside the ward and appears withdrawn.

B. Assessment of the Head

Head is round in shape. Hair is long, thick and coarse, straight and

evenly distributed. Scalp is smooth and white in color, minimal lesions

were noted. Dandruff and lice were seen.

C. Assessment of the Eyes

Her eyes are symmetrical, black in color, almond shape. Pupils

constricts when diverted to light and dilates when she gazes afar,

conjunctivas are pink. Eyelashes are equally distributed and skin around

the eyes is intact. The eyes involuntarily blink.

D. Assessment of the Ears

Ears are clean, no ear wax was noted and approximately of the

same size and shape. Patient can hear normally when spoken softly.
E. Assessment of the Nose

With narrow nose bridge, there were discharges noted upon

inspection. No swelling of the mucous membrane and presence of nasal

hairs were seen.

F. Assessment of the Mouth

She has a complete set of teeth with minimal dental caries noted.

Oral mucosa and gingival are pink in color, moist and there were no

lesions nor inflammation noted. Tongue is pinkish and is free of swelling

and lesions. Lips are symmetrical, appears pale without bits noted upon

observation.

J. Assessment of the Neck

Lymph nodes noted. Neck has strength that allows movement back

and forth, left and right. Patient is able to freely move her neck.

H. Assessment of the Lungs and Thoracic Region

No reports of pain during the inhalation and exhalation. Absence of

adventitious sounds upon auscultation. Respiratory rate 21 breathes per

minute from the normal range of 16-20 breaths per minute.

I. Assessment of the Heart

Patient has an audible heart sound. PMI is heard between 4th - 5th

intercostals space. Heart is pumping well with a pulse rate of 82 bpm from

the normal rate of 60-100 beats per minute.

J. Assessment of the Abdomen

Abdominal movement as with respiration, presence of peristalsis

during auscultation. Presence of rashes and lesions.

K. Assessment of the Upper Extremities

Skin: White in color; presence of marks/scars of wounds in the

arms, neck and legs. Skin is smooth, moist and soft to touch.

Hands: Medium in size with 5 fingernails in each side. Nails are

short, small dusty particles are present.

Arms: Able to move through active ROM. Able to extend arms

in front or push them out to the side.

L. Assessment to the Lower Extremities

Size of the feet is undefined with lines on the sole, presence of scars

and lesions. Ten fingers are present. Nails are clean and short. Patient is

ambulatory.

M. Assessment of the Genitourinary

 With episiotomy dry and intact, urinates 2-4 times a day and has

not defecated yet since her delivery.

N. Assessment of the Perineum

With episiotomy intact, absence of lesions and swelling.

O. Neurological Assessment

Behavior – Patient is silent but is conscious and coherent upon

interaction. She sits and walks if she wants to.

Motor Functioning - Able to move extremities through active

ROM. Able to extend arms front and resist active

as pushed down/up on his hands.

Reflexes - reflexes were present such as the blinking reflex and

deep tendon reflex.

Sensory Functioning – Patient’s sensory system is intact, she was

able to distinguish touch, pain, hot and cold.

ANATOMY AND PHYSIOLOGY OF THE REPRODUCTIVE

SYSTEM
 EXTERNAL GENITALIA

Our overview of the reproductive system begins at the external

genital area— or vulva—which runs from the pubic area downward to the

rectum. Two folds of fatty, fleshy tissue surround the entrance to the

vagina and the urinary opening: the labia majora, or outer folds, and the

labia minora, or inner folds, located under the labia majora. The clitoris,

is a relatively short organ (less than one inch long), shielded by a hood of

flesh. When stimulated sexually, the clitoris can become erect like a man's

penis. The hymen, a thin membrane protecting the entrance of the

vagina, stretches when you insert a tampon or have intercourse.

INTERNAL REPRODUCTIVE STRUCTURE

The Vagina

The vagina is a muscular, ridged sheath connecting the external

genitals to the uterus, where the embryo grows into a fetus during

pregnancy. In the reproductive process, the vagina functions as a two-way

street, accepting the penis and sperm during intercourse and roughly nine

months later, serving as the avenue of birth through which the new baby

enters the world .

The Cervix

The vagina ends at the cervix, the lower portion or neck of the

uterus. Like the vagina, the cervix has dual reproductive functions.

After intercourse, sperm ejaculated in the vagina pass through the

cervix, then proceed through the uterus to the fallopian tubes where, if

a sperm encounters an ovum (egg), conception occurs. The cervix is lined

with mucus, the quality and quantity of which is governed by monthly

fluctuations in the levels of the two principle sex hormones, estrogen and

progesterone.

When estrogen levels are low, the mucus tends to be thick and

sparse, which makes it difficult for sperm to reach the fallopian tubes. But

when an egg is ready for fertilization and estrogen levels are high the

mucus then becomes thin and slippery, offering a much more friendly

environment to sperm as they struggle towards their goal. (This

phenomenon is employed by birth control pills, shots and implants. One of

the ways they prevent conception is to render the cervical mucus thick,

sparse, and hostile to sperm.)

Uterus

The uterus or womb is the major female reproductive organ of

humans. One end, the cervix, opens into the vagina; the other is

connected on both sides to the fallopian tubes.

The uterus mostly consists of muscle, known as myometrium. Its

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 fertilized ovum becomes an

embryo, develops into a fetus and gestates until childbirth.

Oviducts

The Fallopian tubes or oviducts are two very fine tubes leading from

the ovaries of female mammals into the uterus.

On maturity of an ovum, the follicle and the ovary's wall rupture,

allowing the ovum to escape and enter the Fallopian tube. There it travels

toward the uterus, pushed along by movements of cilia on the inner lining

of the tubes. This trip takes hours or days. If the ovum is fertilized while in
the Fallopian tube, then it normally implants in the endometrium when it

reaches the uterus, which signals the beginning of pregnancy.

Ovaries

The ovaries are the place inside the female body where ova or eggs

are produced. The process by which the ovum is released is called

ovulation. The speed of ovulation is periodic and impacts directly to the

length of a menstrual cycle.

After ovulation, the ovum is captured by the oviduct, where it

travelled down the oviduct to the uterus, occasionally being fertilised on

its way by an incoming sperm, leading to pregnancy and the eventual

birth of a new human being.

The Fallopian tubes are often called the oviducts and they have

small hairs (cilia) to help the egg cell travel.

 DRUG LIST

Drug Name and Date Ordered Ordering Physician

Dose

Cephalexin 500mg 1 June 29, 2008 Dr. Bombeo

cap TID

Mefenamic Acid 500mg June 29, 2008 Dr. Bombeo

1 cap TID
 DRUG STUDY

(ORAL MEDS)

GENERIC NAME: CEPHALEXIN

CLASSIFICATION: Anti-Infective

ACTION: Inhibits DNA synthesis by inhibiting DNA gyrase in susceptible

gram negative and gram positive organisms

INDICATIONS: Infectious diarrhea, respiratory tract infection,

infection on the skin structures, bones and joints

CONTRAINDICATIONS: Hypersensitivity to drug or other

fluoroquinolones

ADVERSE REACTIONS:

• CNS: Headache

• CV: Orthostatic Hypotension

• EENT: Blurred Vision

• GI: Nausea and Vomiting, Diarrhea, constipation

• OTHER: Taste

INTERACTIONS: Oral anticoagulants: Increased anti-coagulant effects

NURSING CONSIDERATIONS:

• Advise Patient not to take drugs with dairy or Caffeinated

products

• Inform physician if allergies or rashes abruptly develop

GENERIC NAME: MEFENAMIC ACID

CLASSIFICATION: Anti-Inflammatory, Analgesic

ACTION: Inhibits reuptake of serotonin norepinephrine CNS

INDICATIONS: Moderate to moderately severe pain

CONTRAINDICATIONS: Hypersensitivity with drugs, acute

intoxication with alcohol, physical opioid dependence

ADVERSE REACTIONS:

• CNS: dizziness

• CV: Vasodilation

• EENT: visual disturbances

• GI: Nausea and Vomiting

• GU: urinary retention

• SKIN: pruritus

NURSING CONSIDERATIONS:

• Tell patient that drug works best when taken before pain

becomes severe

• Recommend abstinence from alcohol when taking

medication

• Caution patient that drug can cause dependence

 PROBLEM LIST

Nursing Date Date

Problem #
Diagnosis Identified Evaluated

1 Risk for infection r/t June 30, 2008 July 1, 2008

traumatized skin

tissue 2º to

episiotomy

2 Interrupted breast July 1, 2008 July 1, 2008

feeding r/t infant

illness

3 Situational Low July 1, 2008 Not Evaluated

Self-Esteem r/t

perceived failure at

life events 2º to

rape trauma
 LEARNING OUTCOMES

For at least four weeks of duty, I have encountered several

constraints with regards to the implementation of interventions. It was not

that easy specially that what I am dealing with are lives, lives through

which if jeopardized, can either put me in an obnoxious situation or be

blameworthy for any complications.

Three days of multi-tasking and time management, the OB-

NURSERY ward exposure has taught me how to appropriately handle

pregnant and post partum women. The idea of caring for mothers and

newborns which is not in my lineage is hard. Hard, because some of the

patient’s are uncooperative and non compliant. It isn’t that smooth to

establish an interacting relationship specially that most of the patient’s

admitted in the institution has a low educational attainment. Therefore, I

cannot expect them to fully comprehend the instructions I have imparted.

However, it was a marvelous experience since I was exposed to various

kinds of maternal paragons and procedures which weren’t return

demonstrated yet. Fortunately, there is our clinical instructor who

persistently supervised us and assisted us to make it through with just

minimal errors.

Now, let me get this straight. This is my first time to manage

an individual case study. Adding to that is the fear of making a physiologic

structure of my opted case. One false move and I am screwed. I have

learned to thoroughly assess my patient to comply with the requisites.

Also, I have acquainted myself with regards to establishing rapport with

my patient to have a trusting relationship. Some patients do not totally

disclose themselves because they may find it privacy invading. I have

learned to be patient and control my feelings of anger or annoyance

towards the patient; to respect and accept their beliefs and values without

judging them; to communicate with them therapeutically; to be accurate

and systematic when it comes to charting to avoid errors and reprimands.

Basically, it’s the feeling of confidence you have in yourself that will

facilitate accomplishment and error-free implementation of nursing care. If

you are confident enough to perform the procedures, then the client will

develop trust and confidence to you. The nurse has a lot of responsibilities

to take in, thus, confidence is a very important factor.

The exposure wasn’t centered mainly to rendering care. It

was also focused to building and developing intrapersonal and

interpersonal relationships. I call it, personal growth. To adjust and adapt

with the environment is a humongous task! It’s not that easy. But mingling

with other people helps you identify your strength and weaknesses, and it

aids in modifying what is somehow negative in our attitudes. To sum this

all up, it was a SUCCESS! Thanks be to GOD.

The next time that I’ll render care and perform procedures, I

will try to do my best to attain satisfaction and accomplishment.

 ACKNOWLEDGEMENT

The materialization of this case study wouldn’t be possible

without the aid of the following folks:

To the Almighty Father for the strength given in realizing and

fulfilling the duties and the study; to beloved parents who have always

been supportive all throughout the start of the duty until the end, the toils

and efforts; to dear comrades and colleagues who have been extending

all out help during the rough scenarios, specially to Miss Sheila Marie

Adorador for aiding me in realizing the case study; and to my groupmates

for the overwhelming support, help and camaraderie, for being

cooperative and indulging, that helped me augment my learning and

somehow sharpened my skills.

To our ever lenient but strict clinical instructor, Mr. Paul

Ritchie Pelos, for simplifying what used to be incomprehensible, tricky and

complicated concepts, for assisting us in the various procedures we have

performed, and for being kind to us despite our immaturity