College of our Lady of Mt.

Carmel

A CASE STUDY
ON
NORMAL SPONTANEOUS VAGINAL DELIVERY

Ospital ning angeles (DR)

April 13, 2009 – April 17, 2009

In partial fulfillment
Of the requirements for the
Subject NCM 103

Submitted by:
Rachel Gomez group 8
BSN III
Submitted to:
Mam Zenaida Torrente RN.MAN
 INTRODUCTION

A Normal spontaneous delivery (NSD) occurs when a pregnant woman

goes into labor without use of drugs or techniques to induce labor, and delivers

her baby in the normal manner, without a cesarean section.

There are three stages of normal human birth these are First stage,

second stage and third stage. The first stage of labor starts classically when the

effaced cervix is 3 cm dilated. The second stage begins when the cervix is fully

dilated, and ends when the baby is finally delivered. In the third stage, the

uterus expels the placenta (afterbirth). Maternal blood loss is limited by the

compression of the spiral arteries of the uterus as they pass though the lattice-

like uterine muscles of the upper segment. Normal blood loss is less than 600

mL. The placenta is usually delivered within 15 minutes of the baby being born.

The post-partal period, or the puerperum, refers to the 6-week period

after childbirth. This is a time for maternal changes that are retrogressive

(involution of the uterus and vagina) and progressive (lactation, return of

menstrual cycle and beginning of parental role). Protecting a woman’s health

as these changes occur is important for preserving her future childbearing

function for ensuring that she is physically well enough to incorporate her new

child into the family. This period is popularly termed the fourth trimester of

pregnancy.
 The physical care a woman receives during the post-partal period can

influence her health for the rest of her life. The emotional support she receives

can influence the emotional health of her child and the family and so can be

felt to the next generation.

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 JULY 30, 1992. She was born to parents from

purok 1 anunas Angeles city.

 ANATOMY AND PHYSIOLOGY

Uterine involution is when the uterus decrease in size at a predictable

rate during the postpartal period. After 10 days, it recedes under the pubic bone

and is no longer palpable.

Breastfeeding causes the release of prolactin and oxytocin. Oxytocin is a

hormone that causes uterine contractions. The release of oxytocin while

breastfeeding speeds uterine involution. This may also cause cramps while

breastfeeding in the postpartum period.

Involution of the uterus involves two main process. First, the area where

the placenta was implanted is sealed off to prevent bleeding. Second, the organ is

reduced to its approximate pregestational size.

 The uterus of breast-feeding mother may contract even more quickly,

because oxytocin, which is released with breast-feeding, stimulates uterine

contractions

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.

NURSING INTERVENTIONS AND EVALUATIONS

1. Pain r/t sutures in vaginal area 2* to surgical incision

GOAL: To report pain is relieved

Outcome Indicator: The patient will feel less pain

INTERVENTION EVALUATION
1. Perform a complete assessment of The pain was assessed and patient
pain responded by participating
2. Explain to patient the recovery The patient knew that she is encouraged
period and full healing of sutures to ambulate and healing of sutures is
complete at about 3-4 months
3. Take VS The VS were taken
4. Emphasize compliance to medications Patient said she’ll follow the doctor’s
and doctor’s orders and teachings health teachings
5. Apply therapeutic touch when pain Light hand massage was done and
occurs patient responded well to it
6. Offer diversionary activities like Patient conversed with the student-
conversation nurse

Post Intervention Status: The patient was able to be relieved of the pain; fully
met.

2. Post-Trauma Syndrome: delayed subtype r/t past pregnancyGOAL: to express

emotions of patient and demonstrate ability to deal with emotions
 INTERVENTION EVALUATION
1. Encourage verbalizing of feelings Mom answered toe queries about the
about the death of previous child previous child and expressed grief about
it
2. Inform mom that she’s a mother of 1 She nods and smiles
now and of the responsibilities that
come with it
3. Remind her to take care of her health She says she will follow the doctor’s and
so that she can take good care of her nurse’s orders
new family
4. Promote confidence by a little She smiles
encouragement and praising that she’ll
be a great mom
5. Recommend contact by family Patient says she has good relations with
members for some extra help and family
support

PIS: partially met, patient has only learned from the teachings of the nurse and
doctors and has not yet held her baby.

DRUG STUDY

Name of Drugs Action of Contraindication Nursing

medicine consideration

Cefalexin
• Inhibits • Allergy to • Assess
• Drozid bacteria penicillins and patient’s
500mg l cell cephalosporin previous
TID wall s sensitivity
7 days synthesi reaction to
s. penicillin or
• Antibiot other
ic cephalospor
ins

• Assess
 patient for
any sign of
infection

Mefenamic Acid • Aspirin- • Pregnancy • GI

like and lactation. discomfort,
• Dolfenal drug given after
500mg/cap that has meal.
Q6 for 7 days analgesi • diarrhea or
c, constipation
antipyre , gas pain,
tic and nausea,
anti- vomiting.
inflamm • Assess
atory patient’s
activitie pain before
s. therapy.

Methylergonometri • Act • Pregnancy ast • Abdominal

ne maleate directly and 2nd stage pain
at the of labor • Hypertentio
• Methergin uterine • Patient with n, headache
Mg smooth Preeclampsia • Assess and
TID or QID muscles and eclampsia document
1 week to fundasl tone
stimulat • Monitor
e vital signs
contract • Monitor
ion.
prolactin
levels and
assess for
decrease
breast milk
production.
• For post
partum,
bleeding
report
frequency.

Ferrous Sulfate • Provides • Hypersensitivi • Nausea

element ty to any • Vomiting
al iron. ingredient. • Diarrhea
• Essentia Hemosiderosis • Obtain
l , hemolytic baseline
compon anemia. assessment
ent in of iron
 formati deficiency
on of before
hemoglo starting
bin in therapy
red • Evaluate
blood hemoglobin,
cell hematocrit
develop
ment.

LABORATORY RESULTS

The Normal values of hemoglobin for female is 12 -14 g/100ml, for hematocrit it

should be at the range of 36% - 47% with the average of 40%. Neutrophils should be

within the range of 54% - 57% and for lymphocytes it should be 25% - 40%.

All pregnant women are tested for the Rh factor during the early weeks of

pregnancy. A mother and fetus may have incompatible blood types, the most

common is Rh incompatibility. Rh incompatibility occurs when the mother's blood is

Rh-negative and the father's blood is Rh-positive and the fetus' blood is Rh-

positive. The mother may produce antibodies against the Rh-positive fetus which

may lead to anemia in the fetus. Incompatibility problems are monitored and

appropriate medical treatment is available to prevent the formation of Rh

antibodies during pregnancy.

DISCHARGE PLAN

M – MEDICATION
 • Cefalexin

• Mefenamic Acid

• Methylergonometrine maleate

Instruct patient about the way of taking her medicines. Explain the
proper measurement and time of intake. E.g. 500 mg of Cefalexin should
be taken for 1 week three times a day. 500mg/cap of mefenamic acid
should be taken for one week every six hours and methergin three times a
day or four times a day for three to 1 week.

E - EXERCISE

Encourage the patient to do some exercise every morning such as a simple

walking.

T – TREATMENT

Advice client not to engage in any house chores that might jeopardize her
health.

H – HEALTH TEACHINGS

Encourage and explain the importance of breast feeding to the client.

Breastfeeding especially the first milk, colostrum, can reduce postpartum
bleeding/hemorrhage in the mother, and to pass immunities and other
benefits to the baby. Advice client to let her child expose to mild sunlight in
order to balance and avoid excess bilirubin in the blood.

D – DIET
 Advice client to eat proper diet. Encourage her to eat more vegetables and
frequent intake of liquids. Advise her to eat food which are rich in protein,
iron and vitamin C. Protein helps to repair body tissues, iron provides
formation of Red blood cells and ascorbic acid for helping absorption of
iron.

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 Mam torrente ,To our

ever lenient but strict clinical instructor, 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.