University of Baguio

School of Nursing

A Delivery Room Write-Up

Presented to the Faculty of the

School of Nursing

In

Partial Fulfillment of the

Requirements for the subject

NCENL01

By:

Peralta, Rusell Fernandez

NBA-5

Submitted to:

Nellie C. Palgue, RN

Clinical instructor

December 2014
 TABLE OF CONTENTS

I. Introduction …………………………………………………………………………………………………………………

II. Biographical Data …………………………………………………………………………………………………

A. Patient’s Profile ……………………………………………………………………………………

B. Patient’s Medical History ………………………………………………………………

B.1 Present Health History …………………………………………………………………

B.2 Past Health History …………………………………………………………………………

B.3 Family Health History ……………………………………………………………………

B.4 Socio-economic History …………………………………………………………………

B.5 Obstetric History ………………………………………………………………………………

III. Anatomy and Physiology ……………………………………………………………………………………

A. Female Reproductive System ………………………………………………………………

B. Physiology of Pregnancy ……………………………………………………………………

B.1 Physiological Changes ……………………………………………………………………

B.2 Psychological Changes ………………………………………………………………

C Fetal Development …………………………………………………………………………………

IV. Stages of Labor ……………………………………………………………………………………………………

V. Mechanisms of Labor ………………………………………………………………………………………………

VI. Products of Conception ……………………………………………………………………………………

VII. Instrumentation ……………………………………………………………………………………………

VIII. Newborn Assessment …………………………………………………………………………………………………

IX. Nursing Care Management …………………………………………………………………………………

A. List of Identified Problems

A.1 Actual Nursing Problems …………………………………………………………………

A.2 Potential Nursing Problems …………………………………………………………

B. Nursing Care Plan for the Mother ………………………………………………………

X. Sample Delivery Room Charting For NSD …………………………………………………

XI. Partograph ………………………………………………………………………………………………………………………

XII. Bibliography …………………………………………………………………………………………………………………

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 I. INTRODUCTION

A. Brief Introduction

Delivery Room is a part of the hospital wherein the

process of delivering a baby and other products of labor is

done. Normal spontaneous delivery is the process known which

is delivering a neonate and placenta vaginally and

spontaneously without use of delivery forceps, vacuum and any

other instrumentation. Another procedure done in a delivery

room is D&C or Dilation and Curettage, procedure to scrape and

collect the tissue which is the endometrium form inside the

tissue.

He, Rusell Fernandez Peralta, member of NBA-5,

supervised by clinical instructor, Nellie C. Palgue, was

exposed in the Delivery Room of Baguio General Hospital and

Medical Center, Baguio City last November 27, 2014. He was

able to assist Patient X in a Normal spontaneous delivery.

Then that was the opportunity of him to interview the patient

about health status, past and present and even her socio-

economic status. He is also collaborated to the doctors and

nurses on duty for further information, such as the DR nurse

who revealed some information about the mother’s pregnancy,

partograph and vital signs; the nursery nurse who revealed the

APGAR, BALLARD Score, initial vital signs, antrophometric

measurements of the baby. And lastly he was able to acquire

knowledge about delivery room, NSD, D & C, instruments from

the different books that can be found in the bibliography.

B. GOALS & OBJECTIVES

GOALS:

After the completion of the write up, he shall be able

to: Enhance his knowledge and Skills in Delivery Room, the

process done such as Normal Spontaneous Delivery, D&C and

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other. The nursing care management to the mother, assisting in

NSD, using instruments, Dr charting, doing aftercare and

others.

OBJECTIVES:

They enhance his knowledge and skills in the Delivery Room by:

1. Providing comprehensive information about Delivery room,

Normal spontaneous delivery, D & C, delivery instruments and

others.

2. Assisting the process of NSD and D&C.

3. Listing nursing problems of the mother and his baby.

4. Planning appropriate nursing interventions that is related

to the problem of the client.

5. Proper writing of the Dr chart, following Focus-Data-

action-response (FDAR).

6. Doing proper preparation of instruments and at the end is

doing the aftercare, by chlorinating and cleaning of the

instruments used.

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 II. BIOGRAPHICAL DATA

A. Patient’s Profile

Name: Patient X

Age: 18 y/o

Gender: Female

Civil status: Single

Address: 52 Lower Fairview, Baguio City, Benguet

Birthday: November 21, 1996

Birthplace: Baguio City

Nationality: Filipino

Religion: Roman Catholic

Admission date and time: November 27, 2014 / 11:40 AM

B. Patient’s Medical History

B.1 Present Health History

Two hours prior to admission, patient felt painful

contractions lasting 40 to 60 seconds and occur approximately

every 3 to 5 minutes. The clerk on duty performed internal

examination and cervical dilatation was at 4 cm; thus, she was

brought to labor room. And her admission diagnosis was G1P0

Pregnancy uterine, 39 1/7 weeks Age of Gestation

B.2 Past health history

Last September, Patient had cough and colds but she

didn’t sought for medical intervention. According to her, she

hasn’t hypertensive, with diabetes mellitus and any infection

on the past few months, this is revealed in her chart.

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 B.3 Family Health History

The family has history of asthma on the father side

while in the mother side has the history of hypertension,

Diabetes mellitus, and heart diseases. Presently her

grandmother has Diabetes mellitus.

B.4 Socio-Economic History

The patient communicates well and answers immediately

the questions that he asked. He is cooperative to the

therapeutic regiment or care management done. She was still

living with her parents in the reason that he acclaimed that

she doesn’t have husband, and no one can support except her

family. The family support her during the hospitalization.

They live in a bungalow house is a bit near to the highway. In

their backyard they have bayabas, and some flowering plants.

B.5 Obstetric History

The patient is primigravida. Her first menstruation or

menarche when she is 13 years old. Mother partially immunized

with the First tetanus toxoid. TPAL termed as term, preterm,

abortion, and live revealed (1,0,0,0). She acclaimed that her

last Menstrual Period was February 26, 2014. She also consults

to the near local health unit for prenatal check-up, that

according to her, she done 5 times before she admitted to the

labor room.

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 III. ANATOMY AND PHYSIOLOGY

A. Female Reproductive System

Vagina

– a muscular passageway that leads from the vulva (external

genitalia) to the cervix.

Cervix

– small hole at the end of the vagina through which sperm

passes into the uterus. Also serves as a protective barrier

for the uterus. During childbirth, the cervix dilates

(widens) to permit the baby to descend from the uterus into

the vagina for birth.

Uterus

- hollow organ that houses the baby during pregnancy. During

childbirth, the uterine muscles contract to push out the

baby.

Ovaries

– two organs that produce hormones and store eggs, that was

then fertilized with sperm cells from males.

Fallopian tubes

– muscular tubes that eggs are released from the ovaries and

must be transverse to reach the uterus.

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 B. Physiology of Pregnancy

B.1 Physiological Changes

a. Uterine Changes

The length is ranges from 6.5 to 32 cm, the depth

ranges from 2.5 to 22 cm, width would be from 4 to 24 cm; and

it can weighs from 50 to 1000 g. The uterine wall thickens

early pregnancy from 1 cm to 2cm; thins in pregnancy about6.5

cm thick. The uterine volume can ranges from 2ml to more than

1000 ml. The uterus can hold 4000 g.

The uterine increases it’s size, the blood flow; before

preganancy is 15 to 0 ml/in and end of pregnancy will become

500 to 750 ml. Other changes will be Hegar’s sign (softening

of the cervix); ballottement (rebound that occur)and Braxton

hicks contractions (false labor contractions)

b. Cervical Changes

The cervix become edematous and vascular cause by the

increase circulating estrogen; Goodell’s sign (soft

consistency in the earloebe or “ripe” cervix just befor labor

—butterlike.

C. Vaginal Changes

The pinkish or violet discoloration of the vagina known

as Chadwick’s sign; secretes white vaginal discharges

composed of loosen epithelial cells and connective tissues.

The vaginal environment will become acidic from 7 pH to 4 or

5 pH—this is to favor the growth of Candida Albicans.

d. Breast Changes

Tenderness, fullness, tingling (about 6 weeks) can be

present; increase in breast size; areolas darkens and

increase in diameter. There is also increase in the

vascularity of the breast, there will be prominent veins.

Montgomery’s tubercles enlarge and become protuberant. In the

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16th week—colostrums (thin, watery, high-protein fluid that is

a precursor to the breastmilk) can be expelled from the

nipples.

e. Integumentary System

There will be the presence of Striae gravidarum (pink

or reddish streaks); linea nigra—a narrow, brown line running

from the umbilicus to the symphysis pubis; melasma usually

appears in the face caused by the increase in melanocyte

stimulating hormone secreted by pituitary gland. There is

also vascular spiders (small, fiery red and branching spots);

increase in perspiration; scalp hair growth and palmar

erythema.

f. Respiratory System

There is nasal stuffiness due to increased production

of estrogen; acute sensation of shortness of breath; and

breathing rate is more rapid then normal causes by the

hormonal changes.

g. Temperature

Body temperature increases (the temperature which

increased at ovulation remains elevated) temperature usually

ranges to 36.5 to 37 above.

h. Cardiovascular System

Blood volume increases by atleast 30% up to 50%; at the

end of 1st trimester, blood volume increases gradually; 28th

to 32nd will be the peak level. False anemia (Pseudoanemia)can

also happen this is when the concentration of Hgb and

erythrocytes decline because Plasma volume is greater than

RBC production. In NSD, blood loss can be 300 to 400 ml.

Cardiac output becomes 35% to 50% increase; heart rate will

become 80 to 90 bpm. Blood pressure decreases in 2nd

trimester, prepregnancy level in 3rd trimester.

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 There is also impaired blood flow to the lower

extremities. Supine Hypotension Syndrome can be happen to

pregnant women when they lies on their back; the weight of

the uterus compresses the vena cava, trapping blood in the

lower extremities which causes decreased CO and hypotension.

This can be manifested with lightheadedness, faintness and

palpitations.

i. Gatrointestinal System

There will be slow intestinal peristalsis and the

emptying time of the stomach; decreased gastric acid

secretions. The pregnant can also experience heartburn

(reflux of gastric content); constipation and flatulence

cause by the misplacement of stomach; hemorrhoid or pressure

of uterus affect the anal canal. There is also nausea and

vomiting. Lastly, gingival hypertrophy or enlargement of gums

and hypertyalism or increased salive formation.

j. Urinary System

Women can experience fluid retention caused by the

production of progesterone; increased urine output and

specific gravity decreases. There is also increased GFR

(Glomerular Filtration Rate). Urinary frequency increase; the

ureter’s diameters increases and bladder capacity. There can

be pressure on the right ureter.

k. Skeletal System.

There is gradual softening of the woman’s pelvic

ligaments and joints this is caused by the ovarian hormone

relaxin and placental progesterone. There is also wide

separation of symphysis pubis makes the pregnant woman

difficulty in walking because of the pain waddling gait.

l. Endocrine System

there is slight enlargement of the thyroid gland and

hormone cause the increase production of BMR and 02

10
consumption; in early pregnancy, there is decreased insulin

because of heavy metal glucose demand. After 1st trimester,

increased production of insulin due to antagonist action of

estrogen, progesterone and others. In placenta there is

estrogen and progesterone produced.

m. Immune System

There is decreased IgG (immunoglobulin G) will cause

the mother prone to infection. There’s also increased in WBC

to help counteract the decrease in IgG response.

B.2 Psychological Changes

The pregnant women can experience the following:

a. Ambivalence – interwoven feelings of wanting and not

wanting the pregnancy. Patient X experienced this kind of

feeling though, she’s young, and acclaimed that she has no

husband, that will support her.

b. Grief – the feeling of sadness or melancholy that may

arise vague sense of want or loss, theres is assuming of new

roles.

c. Narcissism – also known as the self-centeredness; an early

reaction to pregnancy. According to patient, she is the

center in the family, all of her needs was given by her

family.

d. Body image – the way the women appears theirselves.

Patient X feels shy when she go out, because she’s pregnant.

e. Stress – this can make the women difficult to make

decisions, awareness to the surrounding as usual or maintain

time management with her usual degree or skill.

f. Mood swings – mood changes; emotional imbalance; the woman

finds acceptable one week, she may find intolerable the next

week.

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g. Changes in Sexual Desire – there can be decrease or

increase of sexual desire. During ovulation, sexual hormones

will increase. During 1st trimester, libido decreases.

Psychological tasks to adjust for pregnancy are the

following:

a. 1st Trimester (Accepting the Pregnancy)

Making the woman feel “more pregnant”. Promoting the

reality of the pregnancy.

b. 2nd Trimester (Accepting the Baby)

Helps her realize that not only she is pregnant but

also ther is child inside her.

c. 3rd Trimester (Parenthood Preparation)

“Nest-building activities” such as planning the

infant’s sleeping arrangements, buying clothes and choosing

names for the infant.

C. Fetal Growth and Development

Milestone of fetal growth and development in the mother’s

womb:

a. End of 4th Gestational Week

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 The embryo’s length is 0.75 cm weighs 400 mg. The

spinal cord is fused and formed at the midpoint. Head is

about one third of the entire proportion. Heart appears as

prominent bulge on the anterior surface. Arms and legs are

bud-like structures. Eyes, ears and nose are rudimentary.

b. End of 8th Gestational Week

Fetal length is 2.5 cm and weighs about 20 grams. Organ

formation is complete; heart is with septum and valves,

beating rhythmically. Facial feature are discernible. Arms

and legs are developed genitalia are forming, but sex cant

determine yet. And abdomen bulges forward.

c. End of 12th gestational Age

Fetal length becomes 7-8 cm, and weighs about 45 g.

Nailbeds are reforming on fingers and toes. Spontaneous

movements are possible. Babinski reflex is elicited. Bone

ossification begin to form. Tooth buds are present, the sex

is now distinguishable.

d. End of 16th Gestational Week

Fetal length becomes 10-17 cm, and weighs about 55-120

g. Lanugo is well formed. Liver and pancreas are functioning.

Urine is present in the amniotic fluid.

e. End of 20th Gestational Week

Fetal length is 25 cm, weighs 223 g; spontaneous

movement can be sensed by mother; hair including eyebrows,

forms on the head. Vernix caseosa begisnd to cover the skin.

Meconium is presnt in the upper intestine. Passive antibody

transfer fro mother to fetus begins

f. End of 24th Gestational Week

Fetal length is 28 to 36 cm, weighs 550g. There is

active production of surfactant. Hearing can be demonstrated

by sudden sounds. This is the age of viability.

g. End of 28th Gestational Week

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 Fetal length is 35 to 37 cm and weighs 1200g. lung

alveoli are almost mature. Testes begins to desecend from

lower admoninal cavity; blood vessels of retina are formed.

h. End of Gestational Week

Fetal length is about 38 to 43, weighs 1600g.

Subcutaneous fat begin to deposited. Moro reflex is elicited.

Iron storage begins; Fingernails reach the end of fingertips.

i. End of 36th Gestational Week

Fetal length is 42 to 48 cm, weighs 1800 to 2700. Sole

of foot has only one to two crisscross creases. Amount of

lanugo begins to diminish.

j. End of 40th Gestational Week

Fetal length becomes 48-52 cm and weighs 3000g. Fetus

kicks actively, hemoglobin convert to adult hemoglobin.

Vernix caseosa is fully formed. Creases on the sole of the

feet cover atleast two thirds of the surface.

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 IV. STAGES OF LABOR

The process of labor and birth is divided into three stages:

FIRST STAGE begins with having contractions that cause

progressive changes

in the cervix and ends with cervix that is fully dilated.

This stage is divided into two phases:

Latent Phase : your cervix gradually effaces (thins out)

and dilates (opens).

Active Phase: the cervix begins to dilate more rapidly, and

contractions are longer, stronger, and closer together.

People often refer to the last part of active labor as

transition.

SECOND STAGE begins once you’re fully dilated and ends with

the birth of your baby. This is sometimes referred as the

“pushing stage”.

THIRD STAGE begins right after the birth of the baby and

ends with the delivery of the placenta.

Every pregnancy is different like the length of labor. For

primigravidas, labor often takes between ten to twenty hours.

For some women, it lasts longer. Labor generally progresses

more quickly for women who’ve already given birth vaginally.

FIRST STAGE: Cervical Stage

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First stage of labor is divided into three phases; the

latent, the active and the transition phase.

LATENT PHASE

It begins with the onset of regular contractions,

effacement and dilation of the cervix to 0-3 cm. It lasts an

average of 6.4 hours for nulliparas and 4.8 hours for

multiparas. Contraction ecome increasingly stronger and more

frequent. A woman should continue to walk and make

preparations for birth.

ACTIVE PHASE

Dilation continues from 3 to 4 to 7 cm. Contractions

becomes stronger, more frequent and more painful, lasting 40

to 40 seconds and occur approximately 3-5 cm. it can be the

frightening time because the labor is progressing and

contractions continue to become stronger.

TRANSITIONAL PHASE

The culmination of the first stage; cervix dilates from

8 to 10 cm. Intensity, frequency and duration of

contractions peaks and there is now an irresistible urge to

push.

SECOND STAGE: Fetal Stage

Begins

with complete dilation of the cervix and ends with delivery

16
of the newborn. Duration may differ among primiparas whis is

longer and multiparas –shorter, but this stage should be

completed within 1 hour after completing dilation.

Contractions are severe at 2-3 minutes interval, with

duration of 50-90 seconds. There is now the mechanisms of

labor. “Crowning” occurs when the newborn’s head or

presenting part appears in the vaginal opening. Episotomy

may be done to facilitate delivery and avoid laceration of

the perineum.

THIRD STAGE: Placental Stage

Begins with delivery of the newborn and ends with

the delivery of the placenta. It occurs in two phases; the

placental separation and expulsion.

PLACENTAL SEPARATION – when the uterus contracts down on an

almost empty interior, there is disproportion between

placenta and contracting wall of the uterus that folding and

separation of placenta occurs. Signs are: globularity of the

uterus, fundus rising in the abdomen, lengthening of the

cord and increased bleeding.

PLACENTAL EXPULSION – after the separation of placenta, it

will now delivered either by natural bearing of mother or

gentle pressure on the contracted uterus.

Contraction of the uterus controls uterine

bleeding, oxytocic drugs are administered to help uterus to

contract.

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 FOURTH STAGE: Recovery and Bonding Stage

It lasts from 1 to 4 hours after birth. Mother and her

baby both recover from the physical process of birth;

maternal organs undergo initial readjustments to the

nonpregnant state. The newborn body system begin to adjust

to extrauterine life and stabilize. Skin to skin contact or

mother-child dyad happens. Mother can breastfeed her baby to

acquire the colustrum that contains antibody that can

protect her baby from disease in atleast 2 months.

V. MECHANISMS OF LABOR

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1. DESCENT

The fetus head is pushed deep into the pelvis in

sideways position, face is to left and the occiput is to the

right.

- in primigravidas, this may occur two weeks before

delivery. This referred to as “lightening”. Lay people Might

call this “dropping”

- in multiparas, this may not occur until dilatation of

the cervix.

2. FLEXION

As fetus head descends, the chin is flexed to come into

contact with the infant’s sternum. Occiput position allows

the occipital bone in the back of the head to laed the way

(smallest diameter of the head).

3. INTERNAL ROTATION

The amount of internal rotation depends on the position

of the fetus and the way the haed rotates to accommodate

itself to the changing diameters of the pelvis.

Enables the fetal head to progress through the maternal

pelvis. The largest diameter of the fetal haed aligns with

the largest diameter of the pelvis.

4. EXTENSION

Occurs when the occiput passes under the symphysis

pubis. This bony structure acts as stable point and provides

leverage, enabling the head to leave the pelvis. Actual

delivery of the head is done by extension.

5. EXTERNAL ROTATION (RESTITUTION)

Occurs as the shoulders and body move through th birth

canal, using the same maneuvers as the head. Shoulders are

delivered similarly to the head, with the anterior shoulder

pressing under symphysis pubis.

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 After shoulders are delivered , the delivery of the

fetus ends with expulsion.

6. EXPULSION

The top of the anterior shoulder is seen next just

under pubis; gentle downward pressure by the physician

delivers the anterior shoulder; the head is gently raised to

deliver the posterior shoulder; the rest of the body follows

the head, which then completes expulsion. The fetus remains

completely passive as it moves through birth canal.

VI. PRODUCTS OF CONCEPTION

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  The aggregate of tissues present in a fertilized gestation; 

in a pregnancy that has been terminated or aborted or

deivered, chorionic villiand/or fetal tissue must be present i

n a specimen to make a definitive diagnosis of intrauterine–

1. FETUS

The passenger is the fetus; the part of the fetus that

has the widest diameter is the head, so this part least

likely to be able to pass through the pelvic ring. The fetus

delivered via NSD 38-40 weeks is appropriate Age of

Gestation, if least or greater, there is possible

complications.

2. FETAL MEMBRANE

The membranous structure that surrounds the developing

fetus and forms the amniotic cavity is derived from fetal

tissue and is composed of two layers; the amnion (inner

layer) and the chorion (outer layer). The amnion is a

translucent structure adjacent to the amniotic fluid, which

provides necessary to the amnion cells. The chorion is more

opaque that is attached to the decidua (maternal tissue

that lines the uterus during pregnancy)

The amnion and chorion are separated by the exocelamic

cavity until approximately three months gestation, when they

become fused. Intact, healthy fetal membranes are required

for an optimal pregnancy outcome.

3. FUNIS (Umbilical Cord)

Also known as birth cor or furnicularis umbilicalis, is

the connecting cord from the developing embryo or fetus to

the placenta. During prenatal developmet, umbilical cordis

21
physiologically and genetically part of the fetus normally

conatins 2 arteries and one vein, buried within Wharton’s

jelly.

4. PLACENTA

The placenta is an organ that connects the developing

fetus to the uterine wall to allow nutrient uptake, waste

elimination and gas exchange via mother;s blood supply.

It forms from both embryonic and maternal tissues, and

hosts an astonishing array of hormonal, nutritional,

respiratory and immunological functions. It is expelled

after the baby is delivered.

5. AMNIOTIC FLUID

This fluid is clear, slightly yellowish liquid that

surrounds the unborn baby (fetus) during pregnancy. It is

contained in the amniotic sac.

While in the womb, the baby floats in the amniotic

fluid. The amount of amniotic fluid is greatest at about 34

weeks (gestation) into the pregnancy, when it averages 800

ml. approximately 600 ml of amniotic fluid surrounds the

baby at full term (40 weeks gestation)

VII. INSTRUMENTATION

The following instruments are used during Normal

Spontaneous Delivery

1. MAYO SCISSOR

-Used for cutting

heavy fascia and

sutures sush as the

perineum during

episiotomy

22
2. STRAIGHT KELLY FORCEP

- Used for grasping anything

which would be inconvenient or

impracticable to graso with

fingers, such as clamping the

cord.

3.

TISSUE FORCEP

- a forcep without teeth,

designed for handling tissues

with minimal trauma during

surgery such as episiotomy and

perineal repair.

4. CURETTE

- Designed for scraping

biological tissue or

debris in a biopsy,

excision or cleaning

procedure such as the

evacuation of the blood

clots after the delivery

of the baby and placenta.

5. METZ SCISSORS

- surgical

scissors designed for

cutting

delicate tissue and blunt

dissection. The scissors

23
 come in variable lengths and have a relatively long shank-

to-blade ratio. They are constructed of stainless steel and

may have tungsten carbide cutting surface inserts. Blades

can be curved or straight.

6. MAYO BASIN

- used as the storage of the sterile instruments, and for

the placenta.

7. NEEDLE HOLDER

- also called needle

driver, is a surgical

instrument, similar to

a hemostat, used

by doctors and surgeon

s to hold asuturing needle for closing wounds

during suturing and surgical procedures.

VIII. NEWBORN ASSESSMENT

24