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.
