NORMAL SPONTANEOUS VAGINAL DELIVERY

Presented to the Clinical Instuctors of the

Notre Dame of Tacurong College
College of Nursing

Richard Deo Rox Alave, RN

Clinical Instuctor

In Partial Fulfillment on the

Course requirement in
NCM 107- RLE

Submitted By:
Amino, Bai Norjanie
Bara, Hussien Jonathan
Lamery, Judy Ann
Lelim, Kevin
Lopez, Jewel Mae
Mala, Samrod
Malicad, Jhazvee
Sepi, Suraida
Temak, Saada
Villalobos, Bai Jehan
BSN 4- DR

December 12, 2012

 TABLE OF CONTENTS

I. Introduction
II. Objectives
*General Objective
* Specific Objectives
III. Patients Data
A. Vital Info
B. Family Background
C. History of Past illness
D. History of Present illness
E. Effects and Expectations of Illness to self and family
F. Growth and Development
IV. Physical Assessment and Review of Systems
V. Definition of Terms
VI. Textbook Discussions
A. Complete Discussion
B. Anatomy and Physiology
C. Etiology and Symptomatology
D. Pathophysiology
VII. Diagnostic Results
VIII. Doctors Order
IX. List of Drugs
X. Drug Study
XI. Prioritized problems
XII. Nursing Care Plan
XIII. Prognosis
XIV. Bibliography
 I. INTRODUCTION

This is the case of a female patient, 22 years old, living at Purok Waling-
waling, Brgy. Mambucal, South Cotabato. She was admitted last December 12,
2012 at 2:15am at South Cotabato Provincial Hospital and was scheduled for a
delivery under the service of Dra. Weeds. She was diagnosed with Pregnancy
Uterine Full Term 39 1/7 weeks Age of Gestation, Cephalic in Labor G2P0.

Pregnancy starts when a male’s sperm fertilizes a females ovum (egg),

and the fertilized ovum implants in the lining of the uterus. Because pregnancy
changes a woman’s normal hormone patterns, one of the first sign of pregnancy
is a missed menstrual period. 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. Labor cannot that be easy: Thereby
implicating that there are process and stages to be undertaken to achieve
spontaneous delivery.

Study shows 7,565 women admitted for labor and delivery in two free-
standing charity birth centers that was established in the Philippines. The births
occurred between February 8, 1996, and December 31, 2003. Midwives
conducted all of the deliveries that occurred in the birth centers. The midwives
were certified professional midwives (CPM) or licensed midwives (LM) from the
USA, Canada and the Philippines. They supervised student midwives enrolled in
the Mercy In Action College of Midwifery & Primary Health Care and dual-
enrolled in the National College of Midwifery's Associate of Science in Midwifery
program. The birthing women were at higher than average risk of a poor
pregnancy outcome because of demographic factors: most were poor, often
malnourished and living in crowded urban slum conditions. Ninety-two percent of
the women and 34% of their spouses were unemployed, and only a little over half
were married. In spite of the poverty, 95% of the women had spontaneous
vaginal birth; 83% had blood loss less than 500 ml; 85% of the babies required
no resuscitation effort; 67% of the labors were without fetal distress or meconium
staining; and 90% of the babies were of normal birth weight. Transfers to a
hospital after admission occurred 7% of the time, with half taking place before
delivery and half after delivery. Neonatal mortality was 4.1 per 1000.

Asking the question of how this condition occurs, this case study will
provide information that may help the readers/listeners understand the cause of
condition. This case study will enhance the knowledge and skills in dealing with
patient who suffers from this condition.

Further complications will be prevented if immediate proper action is

provided and intervention is rendered. Therefore it is important that the health
care provider develop skills in proper management of the client having this
condition.
 II. OBJECTIVES OF THE STUDY

GENERAL OBJECTIVE:

After through research and analysis, we will be able to present important

information about Normal Spontaneous Vaginal Delivery in relation to the client’s
condition, enhance our knowledge and skills in dealing with the client having this
kind of condition and apply this knowledge and skills appropriately in the clinical
setting.

SPECIFIC OBJECTIVES:

After 1-2 hours of presenting the case study, the listeners will be able to:

1) Present correctly the important information regarding patient’s data by

presenting the following:
a) Vital Information
b) Background of the family
c) History of Past Illness
d) History of Present Illness
e) Effects and expectations of the family and the patient to the illness
f) Developmental Data
2) Discuss briefly the result of the Physical Assessment of the client.
3) Discuss comprehensively the complete diagnosis of the client.
4) Discuss briefly the involved anatomy and physiology of the system
affected by Normal Spontaneous Vaginal Delivery.
5) Present the etiology and symptomatology of Normal Spontaneous Vaginal
Delivery.
6) Traces schematically the pathophysiology of Normal Spontaneous Vaginal
Delivery.
7) Enumerate the predisposing and precipitating factors thoroughly.
8) Interpret the laboratory and other diagnostic results to the client.
9) Identify and prioritize the possible diagnosis to the client and formulate
applicable Interventions.
10)Present the drugs that the physician ordered for the wellness of the client
and discuss the mechanism and its effects.
11)Present the prognosis.
 PATIENT’S DATA

A. Vital Information

Patients Name: Mrs. Seashell

Age: 22 years old
Sex: Female
Birth Date: November 11, 1990
Birth Place: Prk. Waling-waling, Brgy. Mambucal, South Cotabato
Address: Prk. Waling-waling, Brgy. Mambucal, South Cotabato
Occupation: Housewife
Tribe: Ilonggo
Citizenship: Filipino
Religion: Roman Catholic
Civil Status: Single
Educational Attainment: College Undergraduate (1st year)
Name of Institution: South Cotabato Provincial Hospital
Date and Time of Admission: December 12, 2012 @ 2:15 am
Chief Compliant: Labor Pain
Admitting Diagnosis: PUFT CIL 39 1/7AOG G2P0
OB history: LMP: March 5, 2012
Attending Physician: Dra. Weeds

Spouse Name: Mr. Sea Urchin

Age: 20 years old
Educational Attainment: Highschool Undergraduate (3rd year)
Occupation: Painter

Parents Name
Father’s Name: Mr. Crab
Age: 50 years old
Occupation: Contractual Worker
Educational Attainment: High School Undergraduate (3rd year)

Mother’s Name: Mrs. Squid

Age: 46 years old
Occupation: Housewife
Educational Attainment: College Undergraduate (1st year)

Siblings:
Name Age Educational Attainment Occupation
1. Mr. Lobster 27 High school graduate Painter
2. Mr. Oyster 24 High school graduate Tricycle Driver
3. Ms. Clownfish 19 College Graduate (Vocational) None
4. Mr. Whale 17 College Undergraduate (1 st year) None
5. Mr. Shark 11 Elementary level (Grade 5) Student
Source of Information:
 Patient
 Patient’s Chart

Source of Medical Financing

 PhilHealth

B. FAMILY BACKGROUND

Mrs. Seashell is the third child among the six children of Mr. Crab and
Mrs. Squid; she is an Ilonggo and a Roman Catholic. She belongs to an
extended type of family.

Presently, Mrs. Seashell and her family are residing in their compound at
Prk. Waling-waling, Brgy. Mambucal, South Cotabato with her live-in partner, five
siblings, and her eldest brother’s family. Her mother and father have their
separate house in the said compound. Her father is a retired army who is
presently working as a contractual worker at STI Marbel and at the same time
Barangay Kagawad in their place while her mother is a housewife. Her father’s
monthly income is 20,000 pesos which is enough for the needs of their family
which includes only her four siblings who are unmarried. Her eldest brother has a
separate income for his own family. Her five siblings namely, Mr. Lobster, 27
years old male who works as a painter, Mr. Oyster, 24 years old male who is a
tricycle driver, Ms. Clownfish, 19 years old female who finished her 2 year course
of Hotel and Restaurant Services, Mr. Whale, 17 years old male who is a College
level, and Mr. Shark, 11 years old male who is a grade 5 pupil. Mr. Sea Urchin
and Mrs. Seashell have been together for 2 years and they are planning to get
married but they are still saving money for it. Mr. Sea Urchin works as a painter
and his weekly income is 1500 pesos which is sufficient for their basic needs.

According to the patient, their usual diet includes rice, vegetables and fish.
She also said that during her entire pregnancy, she loves to eat fruits such as
papaya and mango. Every morning, she is accompanied by her partner to walk
around their neighborhood as part of her daily exercise and she does the usual
household chores when at home. Their family religion is Roman Catholic so
every Sunday, they attend mass together and after that, they usually eat outside
together. Also, they are encouraged by their father, Mr. Crab, to participate
actively whenever there are activities in their Barangay.

With regards to their family health history, she said that her father was
diagnosed to have hepatitis B and her mother has hypertension. The patient and
her siblings do not have potential health problems. At her father side, both of her
grandparents are still alive but do not have any known disease. Same also with
her mother side. The family experienced common illnesses such as fever, cough,
colds and flu. They utilized over the counter drugs such as paracetamol,
decongestant and pain reliever and sometimes they utilized also herbal
medicines such as lagundi for cough. She added that they do not have any
history or serious or viral diseases in both side of their family. According to her,
they do not have any history of kidney disease or cancer to their family or even
any allergies to foods, drugs, and dust.

C. HISTORY OF PAST ILLNESS

According to the patient she was delivered through normal spontaneous

vaginal delivery by a midwife at their house. She was able to complete her
immunizations which consist of 1 dose of BCG, 3 doses of DPT, 3 doses of OPV,
3 doses of hepatitis B vaccine and 1 dose of anti-measles.

The patient experienced nausea and vomiting in the past few months
especially during her first trimester. She did not undergone blood transfusion and
surgery nor experienced any accidents and denies of having allergies on foods
and any of the drugs.

Her menarche was when she was 12 years of age with irregular
succeeding menstrual cycle. She also experienced common childhood illnesses
such as colds, cough and fever and was treated only with over the counter drugs
depending on the illness experienced, such as biogesic, alaxan, mefenamic, and
neozep. She fails to admit herself for medical check-up in relation to inadequate
financial sources. It was her second pregnancy and her last menstrual period
was March 15, 2012.

As Mrs. Seashell stated, her childhood years she had experienced

diseases such as mumps and chicken pox and other common illness
experienced by a normal child.

D. HISTORY OF PRESENT ILLNESS

Nine months prior to admission, the patient experiences probable signs of

pregnancy like amenorrhea and morning sickness. Upon experiencing this
symptoms, she suspected herself to be pregnant and she decide to buy
pregnancy test kit, she was very happy when she saw it was positive. She
immediately informed Mr. Sea Urchin who was also happy with the result.
According to the patient, sometimes she is irritable, easily get tired, and feels
restless. At the second trimester, she said that she experience regular
contractions and she decided to have a regular pre natal check up. Two weeks
prior to admission, she experienced lightening and vaginal spotting.

At 1:00 in the afternoon of December 11, 2012, she experienced lower

flank pain that radiates at the abdomen and she feels the urge to defecate
associated with irregular interval and prolonged contractions so Mr. Sea Urchin
decided to bring him to their Health Center. At around 2:00 in the morning, they
were referred to South Cotabato Provincial Hospital.

E. EFFECTS AND EXPECTATIONS OF ILLNESS TO SELF AND FAMILY

EFFECTS OF ILLNESS TO SELF

Mrs. Seashell was very happy and she wanted to do everything to give her
full time, love, and care for her second baby.

EFFECTS TO FAMILY

When Mr. Sea Urchin knew that his wife is pregnant he prepares all the
necessary things that would be use for their second baby. He was so happy and
excited and gives all support, love, and care for his wife up to the day of the
delivery of their child.

EXPECTATION TO SELF

Mrs. Seashell expects to deliver her baby with good health and she would
be able to perform her activities of daily living.

EXPECTATION TO FAMILY

The family of Mrs. Seashell especially her partner, Mr. Sea Urchin, expected
that after she delivers the baby normally, she would have a fast recovery.
 E. DEVELOPMENTAL DATA

Name of patient: Mrs. Seashell

Age: 22y.o
According to: Erickson’s Psychosocial Development Data
Stage of the patient: Young Adult
Theory: Psychosocial Development

Erickson’s Psychosocial Development Data

Erickson envisions life as a sequence of levels of achievement. Each stage

signals a task that must be achieved. The resolution of the task can be complete,
partial, or unsuccessful. Erickson believes that greater the task achievement, the
healthier the personality of the person, failure to achieve a task influences the person’s
ability to achieve the next task.

YOUNG ADULT (19-40 years old)

STAGE TASK AGE JUSTIFICATION REMARKS

Positive: young Patient has a lived-in
Intimacy vs. adult needs to partner, they lived Positive
Isolation form intimate, 22 together for almost resolution
loving year two years, she got achieved
Age:19-40 relationship with s old pregnant in her first
years old other people. baby but sadly it was
Success leads still birth, and now she
to strong try her best to be a
relationship good partner to his
lived-in partner, and a
Negative: failure good mother to her up
to achieve it coming baby.
results in
loneliness and
isolation
Name of patient: Mrs. Seashell
Age: 22y.o
According to: Havighurst’s Developmental data Task Theory
Stage of the patient: Early Adulthood
Theory: Development task Theory

Description of the theory:

 Robert Havighurst believed that learning is basic to life that people continue to learn
throughout life. He described growth and developmental as accruing during six ages,
each associated with 6-10 tasks to be learned. Havighurst promoted the concept of
developmental tasks in the 1950’s. he studied human behavior in terms of
developmental tasks like; skills or approved behavior pattern, which arise at or about a
certain period of life. In addition, he noted that the successful achievement will lead to
happiness while failure leads to unhappiness and difficulty with later tasks.
 Havighurst’s developmental tasks, provides a framework that the nurse to evaluate a
person’s general accomplishments. However, some nurses find that the broad
categories limit its usefulness as a tool in assessing specific accomplishments,
particularly those infant and childhood.

Stage tasks Justification Remarks

- Selecting a The patient
Early mate and her Partially
adulthood - Learning to live partner are Achieved.
Age 20-40 with a partner not yet
years old - Starting a family married, they
- Rearing children are just living-
- Managing a in. They had
home the chance to
conceive but
sadly it results
to a stillbirth.

Sigmund Freud Psychosexual Theory

Description of theory: According to Freud’s theory of psychosexual development, the

personality develops in five overlapping stages of birth to adulthood. The libido changes, it’s
location of emphasis within the body from one stage to another. Therefore, a particular stage.
The 1st three stages ( oral, anal, phallic) are called pregenital stages. The culminating stage is
the genital stage. Ideally an individual progress through the task of each stage and balance is
achieved between the id, ego and sub ego. Conflict or stress, however can delay or prolong
progression through a stage or cause a person to regress to a previous stage.
 Freud’s psychosexual theory

TASK JUSTIFICATION REMARKS

Stage 1 Oral (birth to 18 months).

Initially sucking, oral satisfaction vital to life, but According to the patient, Achieved
extremely pleasurable in its own right. Late in this stage, she said that during her successfully
the infant begins to realize that the mother/parent is early childhood.
something separate from self.

Stage 2 Anal (12 to18 months to 3 years)

The focus of pleasure changes to anal zone. Children Mrs. Seashell said that Achieved
become increasingly aware of the pleasurable sensation during her early childhood successfully
of this body region with interest in the product of their she has been trained by
effort. This is the stage when a child is first asked to her mother to use the
withhold pleasure to meet parental/ societal toilet.
expectations through the toilet training process.

Stage 3 Phallic or oedipal (3 to 6 years)

According to Freud, the boy becomes more interested in

the penis; the girl becomes aware of the absence of the
According to Mrs. Seashell Achieved
penis. There are times of exploration and imagination as
at this age she was very successfully
the child fantasizes about the parents as first love
attached to her father.
interest. Freud that the sexual wishes are temporarily
driven underground through the action of the developing
super ego or conscience, as the resolution of this stage.
 Stage 4 latency (6 to 12 years )

This is the stage in which Freud believed that the

aggressive and sexual urges, submerged in the
Mrs. Seashell Achieved
unconscious at the end of the oedipal stage, are
remembered that at this successfully
channeled into productive activities that are socially
age she was active in their
acceptable. Latency was thought to be a time of minimal
school works and
sexual interest or activity. Within the educational and
activities.
social worlds of child, there is much to learn and
accomplish. This is where the child places energy and
efforts.

Stage 5 genital (puberty through adulthood).

This is Freud’s final stage. He did not formally continue At this age, Mrs. Seashell
his theory into adulthood. This is a time of turbulence was starting to have her
Achieved
when earlier sexual urges reemerge to be dealt with. own decision pertaining to
successfully
Freud believed that the task of moving from sexual small things and this time
attachment to the parent of childhood to the separation she started to have a
and emotional independence of the adult sexual partner relationship.
is difficult to achieve.

IV. PHYSICAL ASSESSMENT

Date: December 12, 2012

Time: 9:00 am

GENERAL APPEARANCE:

The patient is female adult, hair is not fixed and she wears a clean gown. No body
odor noted; she is conscious and well oriented by the time, place and people around her. She
speaks well with clear and audible voice and was able to understand instructions and health
teachings. The patient is sitting on bed with IVF number 3 of D5LR 1L at the level of 400 cc and
regulated @ 30gtts/min. Hooked @ left cephalic vein. Facial grimace noted, guarding behavior,
irritability and weakness noted.

VITAL SIGNS:

BP: 100/80 mmHg

Temp. 37.1 C

PR: 80 bpm

RR: 24 cpm

Head/ Hair/ Scalp

Inspection: Head is proportional to the body and skull is rounded with symmetrical, flaccid
movement. Hair is black in color and wavy.

Face

Inspection: Facial grimace noted as well as moles noted on some parts of her cheeks.
Eyebrows and eyelashes are equally distributed.

Palpation: No tearing of lacrimal sac during palpation, and smooth.

Ears

Inspection: Ears are symmetrical to the head. No lesions noted, no deformities noted as well
as discharges. Client is able to hear whispered words from 1-3 feet inches. Vibration was heard
equally in both ears.

Palpation: Auricles are mobile, firm and not tender, pinna recoil after it is folded.

Nose
Inspection: External nose are symmetrical, uniform in color and no discharges noted. No
lesions noted. The patient able to smell good and foul odor; air is felt being exhaled through
opposite nares; noiseless.

Palpation: No tenderness and lesions noted upon palpation of maxillary and frontal sinuses.

Lips/ mouth/ teeth/ throat

Inspection: Dry lips noted. Complete set of adult teeth, yellowish in color. The gum is pink in
color, no retraction noted and no gum bleeding noted, the tongue’s position is in the midline,
pink in color and has white pigment and moves freely.

Neck

Inspection: Jugular veins are not inflamed and no stiffness noted, neck muscles are equal in
size with head is at the center. Smooth, controlled movements.

Palpation: Trachea is in midline position, smooth, firm, and non-tender. Lymph nodes is not
palpable, soft mobile, discrete, and non tender.

Respiratory

Inspection: Intercostals spaces are even and relaxed, chest symmetry are equal, position of
sternum is at the level with the ribs, the position of the trachea is at the level with the ribs.

Palpation: No pain or tenderness noted. Symmetrical expansion of the thorax is noted.

Auscultation: Respiration pattern is even, 24/ cpm. unlabored with a normal breathing pattern.

Cardiovascular

Palpation: No vibrations or pulsations are palpated in the chest area. No masses or tenderness
noted.

Auscultation: Rate is 80 beats per minute. Rhythm is regular. Normal heart sound was heard:
“Lab- Dubb”.

Breast

Inspection: Nipples are symmetrical to each other, black in color and increase in size. The
areolas on both breast are black in color, milk secretion noted.

Palpation: Tenderness noted due to engorgement.

Abdomen
Inspection: Presence of linea nigra noted. Moles and scars were also noted.

Palpation: Enlargement organs such as liver, and spleen were not noted.

Genitalia

Inspection: Vaginal discharge noted, perineal bulging noted.

Extremities:

Upper:

Inspection: Arms are symmetrical and appropriate to body size, with normal tan skin color. No
swelling noted on both extremities, with IVF number 3 of D5LR 1L at the level of 400 cc and
regulated @ 30gtts/min hooked at left cephalic vein. Hands have equal grasp strength. Fingers
are compute and no deformities noted. Arms, elbows, shoulder are able to move in range of
motion.

Palpations: No tenderness as well as lesions noted.

Lower extremities:

Inspection: Bone structure and bony landmarks are bilaterally symmetrical and equal, joint
structures are symmetrical & equal. Limited R.O.M of the hip, knee ankle, and toes.

Palpation: Non tender, smooth, warm to touch.

Nails, skin

Inspection: ashes noted, fair skin complexion, no lesion noted, short nails and dirty. Impaired
skin integrity noted.

Palpation: skin is warm to touch and has a capillary refill of 2 seconds.

IV. REVIEW OF SYTEMS

Date: December 12, 2012
Time: 9:00 am

General:

The patient denies that she does not experienced fever or any common illnesses before the
admission but she claimed that she experienced weight changes and body weakness before
the delivery and fatigue after the labor.

Integumentary System:

Skin: Patient denies of having rashes, lumps, sores and itching of the skin.

Hair: Patient claims that she has dandruff and denies of having head lice.

Nails: Patient denies of having dirty and long nails; nor abnormal growth.

Head: Patient denies of having any head injury and syncope prior to the admission. But the
patient claimed of having headache.

Eyes: Patient denies of having blurry vision, trauma, redness, pain, sore, eyes, glaucoma and
cataracts. She also denies of using eyeglasses.

Ears: Patient denies of hearing loss, pain, infection, discharges and by the use of hearing aid.
She also denies of having impacted cerumen and any ear injury before the admission.

Nose: Patient denies loss of smell, obstruction, injury, and epistaxis but claimed that she
experienced colds.

Mouth and throat: Patient denies of having sore throat, sore tongue and denies also of having
dental carries. Denies also of having hoarseness of voice and gum problems.

Neck: Patient denies goiter and stiffness of neck.

Respiratory System: Patient denies cyanosis, having cough and dyspnea as well as smoking.

Cardiovascular System: Patient denies of having chest pain and palpitations.

Muscoskeletal System: Patient denies joint stiffness but claims weakness, back pain, fatigue
and leg cramps.

Gastrointestinal System: Patient denies of having constipation and bowel irregularity.

Endocrine System: Patient denies of having enlargement of thyroid glands and denies that
she has diabetes.

Female Reproductive System: Patient reported that no deformities about to her vagina.

Breast: Patient denies of having breast sore and lumps.

Genitourinary: Patient denies of having dysuria, urgency and hematuria.

Hematology: Patient denies of having any bruises in both extremities.

Psychiatric: Patient denies mood changes, difficulty concentrating and suicidal thought.

V. DEFINITION OF TERMS
VAGINA – is highly distensible musculomembranous canal situated in front of the
rectum and behind the bladder.
- It is tubular, fibromuscular organ lined with mucous membrane that lies in a
transverse fold called Rugae.
- Canal that connect to the external genitalia. It receives the penis and the sperm
ejaculated during sexual intercourse and serve as an exit passageway for
menstrual blood and for the fetus during childbirth.
- Act as the organ of intercourse and also convey sperm to the cervix so sperm
can meet with the ovum in the fallopian tube. It expands to serve as birth canal.

UTERUS – pear shaped muscular organ on the top of the vagina.

- it is the site fro menstruation, implantation of a fertilized ovum and development
of the fetus during pregnancy and labor.
- Receive the ovum from the fallopian tube. Furnish protection to a growing fetus
and expel it from the woman’s body

CERVIX - the lower part of the uterus, opens into the vagina and has a channel that
allows sperm to enter that uterus and menstrual discharge to exit.

FALLOPIAN TUBES – are hollow, cylindrical structures that extend 2-3 inches from the
upper edges of the uterus toward the ovaries.
-the end of each tube into a funnel shaped providing a large opening for the egg
to fall when it is unleaned from the ovary.
- it convey the ovum from the ovaries to the uterus and provide a place for
fertilization of the ovum by sperm.

OVARIES – the ovaries are small, oval shaped glands that are located on either side of
the uterus. The ovaries produce eggs and hormones.
-produce, mature and discharge ova.

VULVA – serves to protect the withdrawal and vaginal opening and is highly sensitive to
touch to increase the female’s pleasure during sexual intercourse.

MONS PUBIS – fatty tissue and skin is covered with pubis after puberty.
-protects the symphysis pubis during sexual intercourse.
LABIA – contains sweat and sebaceous glands. After puberty they are covered with
hair.
-protect the vaginal opening. Lubricate the vulva in response to stimulation.

CLITORIS AND PREPUCE – clitoris is a small, cylindrical mass of erectile tissue and
nerves.
-clitoris like penis is very sensitive to touch, stimulation and temperature and can
become erect.

PERINEUM - short stretch of skin starting at the bottom of the vulva and extending at
the anus.

URETHRA – it is the passage of urine located at the pelvic cavity above bladder.

ENDOMETRIUM – the innermost layer of uterine wall. Contains gland that bathe the
uterine lining.

VI. TEXTBOOK DISCUSSION

 A. COMPLETE DIAGNOSIS

PREGNANCY – period of time between fertilization of the ovum (conception) and birth,
during which mammals carry their developing young in the uterus. The duration of
pregnancy in humans is about 280 days, equal to nine calendar months. After the
fertilized is implanted in the uterus, rapid changes occurs in the reproductive organs of
mother. The uterus becomes larger and more flexible, enlargement of the breasts
begins, and alteration of renal function, blood volume and blood cell count occur.
Movement of the fetus and fetal heartbeat can be detected early in pregnancy.

Reference: www.dictionary.com

HUMAN PREGNANCY – divided into three trimester periods, as means to simplify

reference to the different stages of fetal development. The first trimester carries the
highest risk of miscarriage. During the second trimester the development of the fetus
can start to be monitored and diagnosed. The third trimester often remarks the
beginning of viability, or the ability of the fetus to survive or without medical help,
outside the mother’s womb.

Reference: Mittenporf R. Williams MA, Berkeley CS Cotter PF. The length of

uncomplicated human gestation, OB Stet Gynesol – 1990

PREGNANCY – pregnancy brings both psychological and physical changes to the

woman and her partner. The physiologic changes of pregnancy occur gradually but
eventually affect all organ systems of the woman’s body. Psychological changes occur
in response not only to the physiologic alterations that are occurring but also to the
increased responsibility associated with welcoming new and completely dependent
person to the family. The changes occur in order for the woman to provide oxygen and
nutrients for the growing fetus, as well as extra nutrients for her own increased
increased metabolism during the pregnancy. They ready her body for labor and birth
and for lactation once the baby is born.

Reference: Maternal and Child Health Nursing, Adele Pillitteri

LABOR – is the series of events by which uterine contractions and abdominal pressure
expel the fetus and placenta from the woman’s body. Regular contractions cause
progressive dilatation of the cervix and sufficient muscular force to allow the baby to be
pushed to the outside.

Reference: Maternal and Child Health Nursing, Adele Pillitteri

 THEORIES OF LABOR ONSET

 Labor normally begins when a fetus is sufficiently mature to cope with
extrauterine life, yet not too large to cause mechanical difficulties with birth. In some
instances, labor begins before the fetus is mature (preterm birth). In others labor is
delayed until the fetus and placenta have both passed beyond the optimal point of birth
(postterm birth).

SIGNS OF LABOR

Preliminary Signs

 Lightening
The descent of fetal presenting part into the pelvis occurs approximately 10 to 14
days before labor begins. These changes the woman’s abdominal contour as the uterus
becomes lower and more anterior.

 Increase in Level of Activity

The increase in activity is due to an increase epinephrine release that is initiated
by a decrease in progesterone produced by the placenta.

 Braxton Hicks Contraction

This is true labor contractions. Contractions that begin irregularly but become
regular and predictable. Felt first in the lower back and sweep around the
abdomen in a wave. Continue no matter what the woman’s level of activity.
Increase in duration, frequency and intensity and it achieve cervical dilatation.

 Ripening of the Cervix

This is seen only on pelvic examination. Throughout pregnancy, the cervix feels
softer than normal, like the consistency of an earlobe. At term the cervix
becomes still softer. Ripening is an internal announcement that labor is close at
hand.

SIGNS OF TRUE LABOR

 Uterine Contractions
The initiation of effective, productive, involuntary uterine contractions.

 Show
As the cervix softens and ripens, the mucus plug

that filled the cervical canal during pregnancy is expelled.

 Rupture of membranes
 Labor may begin with rupture of membranes, experienced as either a sudden
gush or scanty, slow seeping of clear fluid from the vagina.

COMPONENTS OF LABOR

 PASSAGE – route the fetus must travel from the uterus through the cervix and
vagina to the external perineum.
 PASSENGER – the fetus
 POWERS OF LABOR – supplied by the fundus of the uterus, are implemented
by uterine contractions, a process that causes cervical dilatation and then
expulsion of the fetus from the uterus.
 PSYCHE – psychological state or feelings that women bring into labor with them.

STAGES OF LABOR

FIRST STAGE

THREE PHASES

 LATENT PHASE
Begins at the onset of regularly perceived uterine contractions and ends when
rapid cervical dilatation begins. The cervical dilatation at this phase is 2-3.

 ACTIVE PHASE
Cervical dilatation occurs more rapidly, going from 4cm to 7cm.

 TRANSITION PHASE
Maximum cervical dilatation of 8 to 10 cm.

SECOND STAGE

The second stage of labor is the period from full dilatation and cervical
effacement to birth of the infant. Contractions change from the characteristic crescendo-
decrescendo pattern to an overwhelming, uncontrollable urge to push or bear down with
contractions as if she had to move her bowels.

THIRD STAGE

The placental stage begins with the birth of the infant and ends with the delivery
of the placenta. Two separate phases are involved: placenta; separation and placental
expulsion.
 B. ANATOMY AND PHYSIOLOGY

1. Mons veneris / mons pubis – a firm, cushion – like elevation of adipose tissue
over the symphysis pubis covered by curly hair or pubic hair forming escutcheon. In
female, pubic hair tends to be triangular distribution, while in male, it tends to be
diamond – shaped. It serves to protect the junction of the pubic bone from trauma.
2. Labia majora – two rounded folds of adipose tissue with overlying skin; they extend
from the mons pubis downward and backward to encircle the vestibule. The outer
surface are covered with hair, where as the inner surface contain sebaceous follicles
which are smooth and moist. Their purpose is mainly to protect the inner delicate
parts of the vulva.
The labia majora are homologous of the scrotum in the male organ. At the same
time, it is the frequent site of varicose vein in the vulva. The arterial blood is supplied
by the internal and external pudendal arteries and a portion of the inferior rectus
artery. It also shared an extensive lymphatic supply with the other structure of vulva,
which facilitates the spread of cancer in female reproductive organ, and obstetric or
sexual trauma may cause hematoma.
Immediately under the skin is a sheet of dartos muscle, which is responsible for
the wrinkled appearance as well as for their sensitivity to heat and cold.
Ordinarily, these structures are 7 – 8 cm. in width and 1 – 1.5 cm. in thickness.

3. Labia minora - two thin, flat, reddish folds of tissue lying between the inner surface
of the labia majora. Each labium minus consists of a thin fold of connective tissue
which when protected, presents a moist, reddish appearance, similar to that of
mucous membrane. The structure is covered by stratified squamous epithelium. It
doesn’t contain hair follicle but it contains many sebaceous follicles and occasionally
a few sweat glands.
 Functions:
a. To lubricate and waterproof the vulvar skin.
b. To provide bactericidal secretion.
The labia minora are classed among erectile structures. This structure is
extremely sensitive and abundantly supplied with several varieties of nerve
endings.

Anteriorly, each divide into 2 parts; the upper pair merges into the prepuce and

the lower one fuse to form the frenulum. Posteriorly, the labia minora fuse to form

fourchette. The labia minora increase in size at puberty and decrease after

menopause due to estrogen level changes.

4. Clitoris - a small, cylindrical highly sensitive erectile organ corresponding to the
male penis. It is made up of erectile tissue which many large and small venous
channels surrounded by large amount of involuntary muscle tissue, the
ischiocarvernosa facilitate erection of the organ.
 Functions :
a. Stimulate and elevate levels of sexual tension.
b. Serve as a landmark in locating urethral opening during
catheterization.
The clitoris measures 5 – 6 mm. long and 6 – 8 mm. across. It has very rich
blood

and nerve supplies. It produces smegma, which along with other vulvar secretion

has a unique odor that may be sexually stimulating to the male.

5. Vestibule – an almond – shaped area that is enclosed by the labia minora laterally
and extends from the clitoris to the fourchette antero-posteriorly. The posterior
portion of the vestibule between the fourchette and the vaginal opening is called the
fossa navicularis and is usually observed only in nulliparous women.
The vestibular bulb is located beneath the mucous membrane of the vestibule
on either side which are almond shaped aggregation of vein 3 – 4 cm. long, 1 – 2
cm. wide and 0.5 – 1 cm. thick. These bulbs lie in close opposition to the ischio-
pubic rami and partially covered by the ischiocavernosus and constrictor vaginal
muscles. These structures are liable to injury and rupture which may result in a
vulvar hematoma or hemorrhage. It is perforated usually by 6 openings: urethra,
vagina, and bartholin’s gland (2) and paraurethral gland (2).

5.1.Urethral meatus / urethral orifice – although not a true part, it is

considered as part of the reproductive system because of its closeness and
relationship to the vulva. It is situated in the middle of the vestibule and
serves as an outlet for urine from the urinary bladder.
5.2.Vulvovaginal / bartholin’s gland – pair of small, pea – sized glands located
within the substances of the labia majora. They correspond to the
bulbourethral of Cowper’s gland in male. Often, they are sites of infection,
abcess and cyst formation. Usually, the openings are not visible or palpable.
The gland secretes a small amount of clear, viscid mucus during sexual
excitement.
5.3.Paraurethral / skene’s gland – a pair of small glands lying on each side of
the urethra. They produce a small amount of mucus and are especially
susceptible to gonorrheal infection. It is homologous to male prostate.
5.4.Vaginal orifice / introitus – occupies the lower portion of the vestibule and
varies considerably in size and shape. The vagina has an abundantly
 vascular supply. Its upper third is supplied by the of the vesicovaginal
branches uterine arteries. Its middle third by the inferior vesical arteries. Its
lower third by the middle hemorrhoidal internal pudendal arteries.
Anteriorly, the vagina is in contact with the bladder and urethra from which is
separated by a connective tissue referred to vesicovaginal septum. Posteriorly
between the lower portion and the rectum is the rectovaginal septum.
Approximately, the upper ¼ of the vagina is separated from the rectum by the
rectouterine or cul-de-sac of Douglas.

The vagina varies in length. The anterior and posterior vaginal walls commonly
measure 6 – 8 cm. and 7 – 10 cm. in length, respectively. The areas around the
cervix at the upper end of the vagina are called fornicles, right and left, anterior
and posterior. The walls are lined with mucous membrane, which falls into folds,
or corrugated formation called rugae. These are referred to the inner wall of
vagina. It is smooth during labor and parturition. It is not present before
menarche and gradually become obliterated after repeated childbirth and
menopause. A healthy vagina has pH of 4.0 – 6.0.

 Functions:
a. serves as excretory duct of the uterus
b. female organ for copulation
c. part of birth canal
Hymen comprised mainly of connective tissue both elastic and collagen. Both
surfaces are covered by stratified squamous epithelium. The hymen can be
broken through strenous physical activities or masturbation. After childbirth,
especially in multipara, the remnants of the hymen from several cicatrized
nodules of varying size called myrtiform caruncles.

6. Perineum – the area extending from the fourchette to the anus. The pelvic and
urogenital diaphragm provides most of the support of the perineum.
6.1.Pelvic diaphragm – consists of the levator ani muscles which is the
principal

muscle that is close to vagina and the coccygeus muscle posteriorly.

The levator ani muscles form a broad muscular sling that originates from
the posterior surface of the superior rami of the pubis, from the inner surface
of the ischial spine and between the 2 sites from the obturator rami.

The pubococcygeus and puborectalis constrict the vagina and rectum and
form an efficient functional rectal sphincter. Their functions are as follows:

a. play a role in sexual sensory function

b. bladder control
c. control perineal relaxation during labor and in expulsion of the fetus during
birth.
6.2.Urogenital diaphragm – located in the hollow of the pubic arch and consists
of the transverse perineal muscles, constrictor of urethra and internal and
external fascial covering. These muscles originate at the ischial tuberosities and
insert into the perineal body. The strong muscle fibers provide support to the anal
canal (sphincter muscle) during defication and to the lower vagina during
delivery.

The perineal body is a wedge – shaped between the vaginal and canal opening
which serves as an anchor point for the muscles, fascia and ligament of the
upper and lower pelvic diaphragm. The perineal body is about 4 cm. wide x 4
cm. deep and continuous with the septum between the rectum and vagina. This
tissue is flattened and stretched as the fetus moves through the birth canal.
 Symptoms Rationale Justification Remarks

Predisposing factors
Sex : Female Only females are Patient is a female. Present
able to get pregnant
because of their
reproductive
system, it has
uterus which is
suitable for the fetus
to live and develop
until the time of
delivery.
Age : 13 and above Females who Patient is now 22 Present
belongs to years old.
reproductive age
(puberty age – 13
years and above)
are the one who is
already able to be
pregnant and those
who are already
ovulating.
Precipitating factors

Coitus Intercourse allows Patient had coitus Present

the delivery of the with her husband.
sperm into the
cervical canal and
travels to the
fallopian tube
(isthmus) to meet
the egg and be
fertilized.
Fertility During fertile days, Patient had sexual Present
there is a release intercourse with her
mature of ovum and partner during fertile
is proliferation on days.
the basal area of
the uterine lining
wherein there’s
sufficient amount of
blood and is
suitable for fetal
growth.
 C. ETIOLOGY

C. SYMPTOMATOLOGY

Symptoms Rationale Justification Remarks

White vaginal Under in the influence of estrogen, the Patient Present
discharge vaginal epithelium and underlying tissues reported that
becomes hypertrophic and enriched with she
glycogen; structures loosen from their experienced
connective tissue attachments in having white
preparation for great distention at birth, vaginal
this increase in the activity of epithelial discharge
cells results in a white vaginal discharge during her
throughout pregnancy. pregnancy.

-5th Edition Maternal and Child Health

Nursing: Care of the Childbearing and
Childbearing Family by Adele Pillitteri, pg.
228)

Amenorrhea Amenorrhea occurs with pregnancy Patient Present

because of the suppression of follicle- verbalized
stimulating hormone by rising estrogen absence of
level. menstruation
last March 5,
-5th Edition Maternal and Child Health 2012.
Nursing: Care of the Childbearing and
Childbearing Family by Adele Pillitteri, pg.
227

Breast changes Early pregnancy, breast is preparting for Pt. experienced Present
the secretion of milk as the pregnancy having breast
progress, breast size increases because changes, “ oo
of hyperplasia of the mammary alveoli daw mas
and fat deposits. The areola of nipple nagdako kag
darkens and its diameter increases from nag itom” as
about 3.5 cm. HPL promotes mammary verbalized by
gland growth in preparation of lactation in the patient.
mother.

-5th Edition Maternal and Child health

Nursing: care of the Childbearing and
childbearing Family by Adele Pillliteri,
Page: 228-189
Nausea and Nausea and Vomiting is maybe related to Patient Present
Vomiting sensitivity to the high level of of chorionic admitted that
 gonodotropine produced by trophoblast she
cells; lowered maternal sugar level experienced
caused by needs of developing embryo; nausea and
and diminished gastric motility. vomiting during
her first month
of pregnancy.
Urinary Frequency of urination early occurs in Patient Present
Frequency early pregnancy due to pressure of the admitted
growing uterus on the anterior bladder. frequency in
Frequency of urination may return at the urination during
end of pregnancy as lightening and the her first
fetal head exert renewed pressure on the trimester, “huo
bladder. daw tong sa
ikadalawa ko
-5th Edition Maternal and Child health kag ikatlo nga
Nursing: care of the Childbearing and pagbuntis sigi
childbearing Family by Adele Pillliteri, ko ka ihi2x.
Page: 236
Constipation As the uterus increases in size, ot ends to Patient Present
push the stomach and the intestines experienced
towards the back and side of the difficulty
abdomen. At about the midpoint of constipation,
pregnancy, this pressure may be “daw tong mga
sufficient to slow intestinal peristalsis and 7 months nag-
the emptying time of the stomach leading umpisa na
heartburn, constipation, and flatulence. budlayan ko
Relaxin hormone produced by the ovary magtae” as
may contribute to decrease gastric verbalized by
motility. Progesterone also has an effect the pt.
on smooth muscle such as that in the
intestine, making it less active.

-5th Edition Maternal and Child health

Nursing: care of the Childbearing and
childbearing Family by Adele Pillliteri,
Page: 223
Quickening It is the fetal movement felt by the Pt. verbalized Present
woman. The fetus can be seen to move that she
on ultrasonography as early as 11th week, experienced
although the mother usually does not feel fetal
this movement until almost 20 weeks of movements, “
gestation. daw mga 5
months ata ko
-5th Edition Maternal and Child health mabatyagan ko
Nursing: care of the Childbearing and nagasipa ang
childbearing Family by Adele Pillliteri, bata” as
 Page: 223; 194 verbalized by
the pt.
Striae As the uterus increase in size, the Patient has Present
Gravidarum abdominal wall must atretch to stretch marks
accommodate it. This stretching can on her
cause rupture and atrophy of small abdomen.
segment of the connective tissue layer of
the skin that leads to pink to reddish
streaks.

-5th Edition Maternal and Child health

Nursing: care of the Childbearing and
childbearing Family by Adele Pillliteri,
Page: 229

Linea Nigra Extra pigmentation generally appears on Patient armpit Present

the abdominal wall. A narrow brown line and inguinal
may form running from the umbilicus to areas becomes
the symphysis pubis and separating the more dark than
abdomen into the right and left before and she
hemispheres. confirmed that
she has linea
nigra, “huo may
ara ngalinya
nga iton diri sa
tiyan ko.
Varicosities The developments of tortuous leg veins Patient had a Present
are common in pregnancy because the visible varicose
weight of the distended uterus puts on the
pressure on the veins returning the blood popliteal.
from the lower extremities. This causes
pooling of blood and distention of vessels.
The veins become engorged, inflamed
and painful.
Lightening Descend of the fetal presenting part into Patient denied Not Present
the pelvis occurs approximately 14 days feeling of
before labor begins. Lightening gives a lessened
woman relief from the diaphragmatic breathing
pressure and shortness of breath that she difficulty or
has been experiencing and in this way feeling of
“lightens” the load. lightening,
“wala man,
-5th Edition Maternal and Child health daw amo man
Nursing: care of the Childbearing and lang gyapon”
childbearing Family by Adele Pillliteri, as the pt.
Page: 229 verbalized.
Bloody show As the cervix ripens, the mucus plug that Patient Present
fills the cervical canal during pregnancy is admitted
expelled. The exposed cervical capillaries release of pink
seep blood as a result of pressure or bloody
exerted by the fetus. The blood mixed mucus from the
with mucus takes on a pink tinge and is vagina.
referred to as “show” or “bloody show”
Pain During contractions, blood vessels Patient Present
constrict reducing the blood supply to admitted
uterine and cervical cells, resulting in perception of
anorexia to muscle fibers. This anoxia mild pain but
can cause pain in the same way as the not that
pain of a heart attack. As labor frequent, “
progresses and contractions becomes masakit gaabot
longer and harder, the anoxia to cells abot, kagaina
increases and the pain intensifies. medyo kis-a2x
pa, subong ga
sigi2x na”.
 VII. HEMATOLOGY

Complete Blood Count - The complete blood count (CBC) is one of the most commonly ordered blood

tests. The complete blood count is the calculation of the cellular (formed elements) of blood. These

calculations are generally determined by special machines that analyze the different components of blood

in less than a minute. A major portion of the complete blood count is the measure of the concentration of

white blood cells, red blood cells, and platelets in the blood.

Laboratory Result NormalValue Indication Nursing Responsibility

Hemoglobin mass 111 120-160 Decrease Decrease due to labor
that causes blood
loss.
Hematocrit 0.34 0.40-0.50 Decrease: Ensure that the
Hemorrhage, patient undergone
Anemia blood transfusion
Segmenter 0.73 0.55-0.60 Increase may Encourage patient to
indicate infection. increase intake of
Vitamin C rich foods
for tissue repair. Eat
more fruits and
vegetables
Lymphocyte 0.20 0.35-0.40 Decrease- may Lymphocyte will not
follow infection increase because
segmenters is in the
first line of defense.
Erythrocyte V◦ 0.35 0.36-0.40 Decrease rate of No contract of auto-
red blood cell immune reaction.
Fraction production.
Blood type B To know the
patient’s blood
type so that in
case of blood
transfusion due to
increase blood
loss upon delivery.
 DOCTOR’S ORDER

Time and ORDER RATIONALE REMARKS

Date

December *Please admit ~The patient was The patient

12, 2012 @ admitted for further was
2: 30am observation and admitted.
management.

*NPO ~ The patient is not

allowed to eat whatever The patient
she like. Patient might was
vomit during delivery monitored.
and high risk for
aspiration

* Monitor maternal V/s ~TPR of the patient is to

and FHT TPR q 4˚ determine current patient The patient
condition as well as the was
fetus and to note instructed.
significant changes. This
is also for baseline data
and to help physician to
further interpret or
diagnose the proper care
for the patient.
IV fluid was
~ This is done to hooked
*D5LR 1L x 20
gtts/min maintain the fluid and
electrolytes balance of
the patient as well as it
will serve as the partial
for IVTT medicine and it
is regulated at 20
gtts/min to prevent
toxicity and circulatory
overload.
Labs: ~These laboratory Laboratory
examination was examination
CBC, BLD ordered by the physician was ordered
TYPING to determine and role
out the condition of the
patient.

~Prevent infection Medication

Cefalexin 500 g 1 cap * given.
1 week

~This is done to monitor

the patient’s condition Pt & V/S
*Monitor maternal V/s and to note any changes monitored
and FHT TPR q 4˚ to the vital sign of the as ordered.
patient and the fetus.

~Tell Physician any

* Refer for problem Referred
problems regarding pt.
situation.
IX. List of Drugs

1. Ferrous Sulfate, 100mg, Oral, OD

2. Methergine, 1 amp, IVTT, after birth

3. Oxytocin, 1g, Incorporation to IVF, q6
 XIII.PROGNOSIS

Prognosis Good Fair Poor Justification

Onset of Illness - Patient experience

labor pain 8 hours
‫׀‬ prior to admittion.
She suffers irregular
pain. She does some
walking and rubbing
of the back to relieve
the pain. When she
went to the hospital ,
the pain continous
but it stops
sometimes.
Duration of - Patient suffered labor
Illness pain every2-3 mins.,
she can tolerate the
pain with the use of
I depth breathing
exercise after the
contraction to ease
the pain.

Hygiene - Patient cannot do

personal hygiene
I without any support
from family members
because she is a little
bet weak.
Diet - Patient how to
balance diet, she
have her meal on
time. She usually eat
‫׀‬ fruits and drinking
fruit juices.
Age - Patient is a 22 years
old and she is on 1st
time of delivery. She
 don’t have any
complication felt
I during pregnancy but
only pain prior to
admission.
Performance - Patient can do work
Level but with assistance
because she has not
totally recovered yet
I from after giving birth,
her body cannot
support her needs to
do her usual
activities.
Willingness to - Patient shows
udergo willingness to
treatment undergo treatment for
the reason that she
wants to have a fast
recovery by having
I an adequate rest and
follows prescribed
medicines. She noted
all the instructions of
the doctor that to take
a rest to regain
strength.
Family support - Families gaves their
full support to our
patient from onset of
labor, during delivery
and during treatment.
They provide
patient’s needs in
terms of foods and
clothes. They always
‫׀‬ at the patient side to
attain the needs of
the patient.

6/8 1/8 1/8

 GOOD - 6/8 x 100 = 50

FAIR - 1/8 x 100 = 37.5

POOR - 1/8 x 100 = 12.5

Remarks:

Prognosis shows, the patient condition in getting well is good, because most of

the criteria have good remarks. In this prognosis the pt will recover faster and regain her

strength in short duration of time, with the full support of her family.

XIV. BIBLIOGRAPHY
1. 1995 Springhouse Nursing Drug Handbook

2. 2001-02 Drug Information Handbook For Nursing

3. Nursing Care Plans / Guidelines for Individualizing Patient Care, 6th Edition /
Marilynn E.

Doenges, Mary Frances Moorhouse, Alice C. Geissler-Murr

4. Maternal & Child Nursing 2nd Edition / Emily Slone McKinney,Susan Rowena
James,

Sharon Smith Murray, Jean Weiler Ashwill

5. Maternal & Child Health Nursing / Care of the Childbearing & Childrearing By
Adele

Pilliteri

6. Fundamentals of Nursing/Concepts, process, and Practice By Kozier

7. Mittenporf R. Williams MA, Berkeley CS Cotter PF. The length of

uncomplicated human gestation, OB Stet Gynesol – 1990