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NORMAL SPONTANEOUS VAGINAL

DELIVERY
NSVD

Nursingcasestudy.blogspot.com

INTRODUCTION

Pregnancy, the state of carrying a developing embryo or fetus


within the female body. This condition can be indicated by positive results
on an over-the-counter urine test, and confirmed through a blood test,
ultrasound, detection of fetal heartbeat, or an X-ray. Pregnancy lasts for
about nine months, measured from the date of the woman's last
menstrual period (LMP). It is conventionally divided into three trimesters,
each roughly three months long.

When gestation has completed, it goes through a process


called delivery, where the developed fetus is expelled from the mothers
womb. There are two options of delivery: Cesarean section and NSVD or
normal spontaneous vaginal delivery. A cesarean section is a surgical
incision through the mothers abdomen and uterus to deliver one or more
fetuses. NSVD or normal spontaneous vaginal delivery is the delivery of
the baby through vaginal route. It can also be called NSD or normal
spontaneous delivery, or SVD or spontaneous vaginal delivery, where the
mother delivers the baby with effort and force exertion.

Normal labor is defined as the gradual subjugation and


dilatation of the uterine cervix as a result of rhythmic uterine contractions
leading to the expulsion of the products of conception: the delivery of the
fetus, membranes, umbilical cord, and placenta. Laboring cannot that be
easy; thereby implicating that there are processes and stages to be
undertaken to achieve spontaneous delivery. Through which, Obstetrics
have divided labor into four (4) stages thereby explaining this continuous
process.

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


regular uterine contractions and ends with complete cervical dilatation at
10 centimeters. This stage is broken down into three (3) phases: the Early
phase, where the contractions are usually very light and maybe
approximately 20 minutes or more apart from the beginning, gradually
becoming closer, possibly up to five minutes apart; the Active phase,
where contractions are generally four or five times apart, and may last up
to 60 seconds long. Cervix dilates with 4-7 cm and initiates a more rapid
dilatation. It is known that to get through active labor, mobility and
relaxations are done to increase contractions; and the Transition phase,
where it is definitely known as the shortest phase but the hardest,
contractions maybe two or three times apart, lasting up to a minute and a
half, about approximately 8-10 cm of cervical dilatation. Some women will
shake and may vomit during this stage, and this is regarded as normal.
Most of the time, women would find a comfortable position to acquire
complete dilatation.

STAGE II: This stage lasts for three or more hours. However,
the length of this stage depends upon the mothers position (e.g.; upright
position yields faster delivery). Once the cervix has completely dilated,
the second stage had begun. This stage ends with the expulsion of the
fetus.

STAGE III: This stage focuses on the expulsion of the


placenta from the mother. Placenta exclusion is much more easier than
the delivery of the baby because it includes no bones, and this is during
this stage that the baby is placed on top of the mothers womb.

STAGE IV: No more expulsions of conception products for this


stage as this is generally accepted as POST PARTUM juncture. This phase
is from the placental delivery to full recovery of the mother.

Labor and delivery of the fetus entails physiological effects


both on the mother and the fetus.

In the cardiovascular system, the

mothers cardiac output increases because of the increase in the needed


amount of blood in the uterine area. Blood pressure may also rise due to
the effort exerted by the mother in order expel the fetus. There could also
be a development of leukocytes or a sharp increase in the number of
circulating white blood cells possibly as a result of stress and heavy
exertion. Increased respiratory may also occur. This happens as a
response to the increase in blood supply in order to increase also the
oxygen intake.

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


contractions. Braxton Hicks are sporadic uterine contractions that
actually start at about 6 weeks, although one will not feel them that early.
Most women start feeling them during the second or third trimester of
pregnancy. True labor is felt in the upper and mid abdomen and leads to
the cervical changes that define true labor.

With delivery imminent, the mother is usually placed supine with


her knees bent (ie, the dorsal lithotomy position). An episiotomy (an
incision continuous with the vaginal introitus) may be performed at this
time. Episiotomy may ease delivery of the fetal head and allow some
control over what may otherwise be an uncontrolled perineal laceration.
However, many providers no longer perform routine episiotomy, since it
may increase the risk of rectal injury and are larger than the spontaneous
laceration.

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


options for pain control are available, ranging from intramuscular or
intravenous doses of narcotics, such as Meperidine (Demerol), to general
anesthesia. Regional nerve blocks, such as a pudendal block or local
infiltration of the perineal area can also be used. Further options include
epidural blocks and spinal anesthetics.

Nursing Health History


Nursing health history is the first part and one of the most
significant aspects in case studies. It is a systematic collection of
subjective and objective data, ordering and a step-by-step process
inculcating detailed information in determining clients history, health
status, functional status and coping pattern. These vital informations
provide a conceptual baseline data utilized in developing nursing
diagnosis, subsequent plans for individualized care and for the nursing
process application as a whole.

In keeping the private life of my patient and in maintaining


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

Patient P was born on December 19, 1992. She was born to parents
from Surigao Del Norte, but she didnt actually live with them. She was
technically abandoned to the relatives, but those people could not
essentially foster her. She stayed at the Department of Welfare and Social
Development or DSWD and spent her 15 years of existence. Her

education was funded mainly by volunteers and charitable foundations. At


the same time, she compensated for it by means of helping in chores and
accomplishing tasks in the said foundation.

She grew up with other abandoned children with questions in her


mind. But to that, she never completely disclosed herself. Patient P is a
victim of sexual abuse. She was raped and was unable to resist because
of her innocence. She doesnt talk that much. Often times, she paces back
and forth inside the ward, sits silently on her bed and sometimes quietly
stares outside the window. When tried to ask about what she knows of her
family, she could only turn silent, and somehow implies to ask the next
question to her. But when chance punched, I grasped it and coiled directly
to my point. Unfortunately, hesitancy was felt from the kind of thing that
was wanted to be discussed. The issue was not forced until her watcher,
which has no relation to her, revealed the reason behind her pregnancy.

According to Patient Ps watcher, it was on a cold night in


September 2007, when Patient P came home from school: Upon nearing
the center, a man, which she identified as a newcomer to the center,
blocked and harassed her brutally. She struggled to let go from the
ruthless hands of the unaccustomed man. Patient P was threatened that if
shed make any noise, shed get killed. Ill-fatedly, she was held powerless
to the man, and the crime had happened. Fortunate enough that she
wasnt killed, she thanked the Lord for sparing her life. Although alive, she
felt very much unfair about her situation. She could only tell, Kabata pa
kaayo nako nahimong inahan, nganong nahitabo man pud ni.. . Patient P
conceived the baby and bore it for 9 months. For the first trimester, she
couldnt believe and accept her fate, and sometimes thought of slight
curses to the person who did the crime. But somehow, she felt a jot of
excitement of a having a baby unexpectedly. She even verbalized, Wa

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


nako ang bata.. Wala man siyay sala.

According to Erik Eriksons Developmental Task of adolescence,


from the age of 10 to 18 years old, Patient P belonged to the IDENTITY
versus ROLE CONFUSION, which proposes that the adolescent is newly
concerned with how he or she appears to others. Development mostly
depends upon what is done to us. From here on out, development
depends primarily upon what we do. And while adolescence is a stage at
which we are neither a child nor an adult, life is definitely getting more
complex as we attempt to find our own identity, struggle with social
interactions, and grapple with moral issues.

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


On the same date was her EDC or expected date of confinement. The age
of gestation is 39 weeks by LMP. Her LMP was September 2007, exact date
unrecalled. She was admitted to Butuan Medical Center at around 2:40am
with blood pressure of 140/90 mmHg. She was examined by Dr. Bombeo
and found out that she was fully dilated. By 2:45am, 5 minutes after her
admission, doctors orders were carried out:

#1 D5LR I Liter started @ 20 gtts/min

TPR q 4

NPO

CBC blood typing; hbsAg requested

Labor watch

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


minutes, she was admitted in the ER accompanied by the staff, positioned
on the DR table with final preparation done.

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


centimeters in length baby girl with these statistics:

Head Circ:

Chest Circ: 30 cm

Abd Circ:

32 cm

20 cm

Extemporaneously, the baby cried with the same breathing time of


3:36am. Patient Ps placenta was expelled spontaneously by 3:47am with
blood pressure of 130/80. Oxytocin 10 units was infused to IVF;
Methergine I amp IVTT; her uterus was firm and contracted and was
admitted to ward via stretcher. During her labor, she was anesthetized
with Lidocaine HCl 5cc.

After her delivery, she was admitted to the Ob ward with repaired
episiotomy. Post partum doctors orders were as follows which was carried
out:

DAT (Diet as Tolerated)

Ice pack over hypogastrium

Perineal care

Oxytocin 10 U infused to IVF and;

Methergine I amp IVTT.

Cephalexin I amp IVTT

Mefenamic Acid 500mg I cap TID

May room in

Breastfeed per demand

Patient Ps temperature was monitored until stable.

On the following day, June 30, 2008, doctors order was to secure
HBsAg result. Patient Ps baby was admitted to NICU because of frequent
vomiting and fever. The staff continued to monitor her vital signs and
administered prescribed medications. As a student nurse, I also did my
assessment towards my patients condition. Upon assessing, I was able to
take and record her vital signs:

T = 37.3c

82 bpm

21 cpm

120/70 mmHg

Patient P wasnt able to take a bath because of her beliefs. Since


she has an episiotomy wound, she is at risk for infection. I made my
independent nursing interventions. I explained to her the importance of
proper hygiene to prevent the occurrence of infection. Emphasis on eating
foods rich high protein to promote wound healing was imparted. She
verbalized, Sakit man akong totoy mam. So, I encouraged her to let her
baby continuously suck to both breasts when received back from NICU,
that is to relieve her engorgement. Also, I instructed her to increase fluid
intake at least 8 oz per hour to facilitate increase in milk production, and
to eat nutritious foods such as fruits and vegetables to nourish her baby
well.

On July 1, 2008, doctors orders were noted:

Continue meds

Repeat hemoglobin

MGH after IE and if hemoglobin is OK

By 1:25 pm:

Defer MGH

Secure and transfuse 4 units FWB/wg (fresh whole


blood) properly crossmatched

Antamine I amp 10,000 units

BT (blood transfusion)

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


brief history about her case. I aided her in securing her blood by
persistently going with her to the blood bank. Patient P was advised to
take adequate rest in fear of hypotension due to her low hemoglobin,
59G/L. So, it was me and her watcher who was always on the go. I
continued to administer her medications per prescription:

Cephalexin 500mg I cap TID

Mefenamic Acid 500mg I cap TID

July 2, 2008, doctors order was to follow up 4 units of blood. Patient


P was reinserted with IV D5LR.
On July 7, 2008, Patient P was transfused with 4 units of fresh whole
blood, baby was already on mothers side, and were about to go home.
She was seen with the health workers facilitating her discharge from the
hospital.

PHYSICAL ASSESSMENT

Physical examination follows a methodical head to toe format in the


Cephalocaudal assessment.

This

is

done

systematically

using the

techniques of inspection, palpation, percussion and auscultation with the


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

sphygmomanometer, tape measure and stethoscope and also the senses.


During the procedure, I made every effort to recognize and respect the
patients feelings as well as to provide comfort measures and follow
appropriate safety precautions.

A. General Physical Assessment

Patient is a 15 year old female, stands 54, with pulse rate of 82


beats pre minute, respiratory rate of 21 breathe per minute and a
temperature of 37.3 C. She is conscious and coherent upon interaction
but answers only the questions she is comfortable with. Most of the time,
she is pacing inside the ward and appears withdrawn.

B. Assessment of the Head

Head is round in shape. Hair is long, thick and coarse, straight and
evenly distributed. Scalp is smooth and white in color, minimal lesions
were noted. Dandruff and lice were seen.

C. Assessment of the Eyes

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


constricts when diverted to light and dilates when she gazes afar,
conjunctivas are pink. Eyelashes are equally distributed and skin around
the eyes is intact. The eyes involuntarily blink.

D. Assessment of the Ears

Ears are clean, no ear wax was noted and approximately of the
same size and shape. Patient can hear normally when spoken softly.

E. Assessment of the Nose

With narrow nose bridge, there were discharges noted upon


inspection. No swelling of the mucous membrane and presence of nasal
hairs were seen.

F. Assessment of the Mouth

She has a complete set of teeth with minimal dental caries noted.
Oral mucosa and gingival are pink in color, moist and there were no
lesions nor inflammation noted. Tongue is pinkish and is free of swelling
and lesions. Lips are symmetrical, appears pale without bits noted upon
observation.

J. Assessment of the Neck

Lymph nodes noted. Neck has strength that allows movement back
and forth, left and right. Patient is able to freely move her neck.

H. Assessment of the Lungs and Thoracic Region

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


adventitious sounds upon auscultation. Respiratory rate 21 breathes per
minute from the normal range of 16-20 breaths per minute.

I. Assessment of the Heart

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


intercostals space. Heart is pumping well with a pulse rate of 82 bpm from
the normal rate of 60-100 beats per minute.

J. Assessment of the Abdomen

Abdominal movement as with respiration, presence of peristalsis


during auscultation. Presence of rashes and lesions.

K. Assessment of the Upper Extremities

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


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

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


short, small dusty particles are present.

Arms:

Able to move through active ROM. Able to extend arms

in front or push them out to the side.

L. Assessment to the Lower Extremities

Size of the feet is undefined with lines on the sole, presence of scars
and lesions. Ten fingers are present. Nails are clean and short. Patient is
ambulatory.

M. Assessment of the Genitourinary

With episiotomy dry and intact, urinates 2-4 times a day and has
not defecated yet since her delivery.

N. Assessment of the Perineum

With episiotomy intact, absence of lesions and swelling.

O. Neurological Assessment

Behavior Patient is silent but is conscious and coherent upon


interaction. She sits and walks if she wants to.

Motor Functioning -

Able to move extremities through active

ROM. Able to extend arms front and resist active


as pushed down/up on his hands.

Reflexes - reflexes were present such as the blinking reflex and


deep tendon reflex.

Sensory Functioning Patients sensory system is intact, she was


able to distinguish touch, pain, hot and cold.

ANATOMY AND PHYSIOLOGY OF THE REPRODUCTIVE


SYSTEM

EXTERNAL GENITALIA

Our overview of the reproductive system begins at the external


genital area or vulvawhich runs from the pubic area downward to the
rectum. Two folds of fatty, fleshy tissue surround the entrance to the
vagina and the urinary opening: the labia majora, or outer folds, and the
labia minora, or inner folds, located under the labia majora. The clitoris,
is a relatively short organ (less than one inch long), shielded by a hood of
flesh. When stimulated sexually, the clitoris can become erect like a man's
penis. The hymen, a thin membrane protecting the entrance of the
vagina, stretches when you insert a tampon or have intercourse.

INTERNAL REPRODUCTIVE STRUCTURE

The Vagina
The vagina is a muscular, ridged sheath connecting the external
genitals to the uterus, where the embryo grows into a fetus during
pregnancy. In the reproductive process, the vagina functions as a two-way
street, accepting the penis and sperm during intercourse and roughly nine
months later, serving as the avenue of birth through which the new baby
enters the world .
The Cervix
The vagina ends at the cervix, the lower portion or neck of the
uterus. Like the vagina, the cervix has dual reproductive functions.
After intercourse, sperm ejaculated in the vagina pass through the
cervix, then proceed through the uterus to the fallopian tubes where, if
a sperm encounters an ovum (egg), conception occurs. The cervix is lined
with mucus, the quality and quantity of which is governed by monthly

fluctuations in the levels of the two principle sex hormones, estrogen and
progesterone.
When estrogen levels are low, the mucus tends to be thick and
sparse, which makes it difficult for sperm to reach the fallopian tubes. But
when an egg is ready for fertilization and estrogen levels are high the
mucus then becomes thin and slippery, offering a much more friendly
environment to sperm as they struggle towards their goal. (This
phenomenon is employed by birth control pills, shots and implants. One of
the ways they prevent conception is to render the cervical mucus thick,
sparse, and hostile to sperm.)
Uterus
The uterus or womb is the major female reproductive organ of
humans. One end, the cervix, opens into the vagina; the other is
connected on both sides to the fallopian tubes.
The uterus mostly consists of muscle, known as myometrium. Its
major function is to accept a fertilized ovum which becomes implanted
into the endometrium, and derives nourishment from blood vessels which
develop exclusively for this purpose. The fertilized ovum becomes an
embryo, develops into a fetus and gestates until childbirth.
Oviducts
The Fallopian tubes or oviducts are two very fine tubes leading from
the ovaries of female mammals into the uterus.
On maturity of an ovum, the follicle and the ovary's wall rupture,
allowing the ovum to escape and enter the Fallopian tube. There it travels
toward the uterus, pushed along by movements of cilia on the inner lining
of the tubes. This trip takes hours or days. If the ovum is fertilized while in

the Fallopian tube, then it normally implants in the endometrium when it


reaches the uterus, which signals the beginning of pregnancy.
Ovaries
The ovaries are the place inside the female body where ova or eggs
are produced. The process by which the ovum is released is called
ovulation. The speed of ovulation is periodic and impacts directly to the
length of a menstrual cycle.
After ovulation, the ovum is captured by the oviduct, where it
travelled down the oviduct to the uterus, occasionally being fertilised on
its way by an incoming sperm, leading to pregnancy and the eventual
birth of a new human being.
The Fallopian tubes are often called the oviducts and they have
small hairs (cilia) to help the egg cell travel.

DRUG LIST

Drug Name and

Date Ordered

Ordering Physician

June 29, 2008

Dr. Bombeo

June 29, 2008

Dr. Bombeo

Dose
Cephalexin 500mg 1
cap TID

Mefenamic Acid 500mg


1 cap TID

DRUG STUDY

(ORAL MEDS)

GENERIC NAME:

CEPHALEXIN

CLASSIFICATION: Anti-Infective
ACTION: Inhibits DNA synthesis by inhibiting DNA gyrase in susceptible
gram negative and gram positive organisms

INDICATIONS:

Infectious

diarrhea,

respiratory tract infection,

infection on the skin structures, bones and joints


CONTRAINDICATIONS:

Hypersensitivity

to

drug

or

other

fluoroquinolones
ADVERSE REACTIONS:

CNS: Headache

CV: Orthostatic Hypotension

EENT: Blurred Vision

GI: Nausea and Vomiting, Diarrhea, constipation

OTHER: Taste

INTERACTIONS: Oral anticoagulants: Increased anti-coagulant effects


NURSING CONSIDERATIONS:

Advise Patient not to take drugs with dairy or Caffeinated


products

Inform physician if allergies or rashes abruptly develop

GENERIC NAME:

MEFENAMIC ACID

CLASSIFICATION: Anti-Inflammatory, Analgesic


ACTION: Inhibits reuptake of serotonin norepinephrine CNS
INDICATIONS: Moderate to moderately severe pain
CONTRAINDICATIONS:

Hypersensitivity

with

drugs,

acute

intoxication with alcohol, physical opioid dependence


ADVERSE REACTIONS:

CNS: dizziness

CV: Vasodilation

EENT: visual disturbances

GI: Nausea and Vomiting

GU: urinary retention

SKIN: pruritus

NURSING CONSIDERATIONS:

Tell patient that drug works best when taken before pain
becomes severe

Recommend

abstinence

from

alcohol

when

medication

Caution patient that drug can cause dependence

taking

PROBLEM LIST

Nursing

Date

Date

Diagnosis

Identified

Evaluated

Risk for infection r/t

June 30, 2008

July 1, 2008

July 1, 2008

July 1, 2008

July 1, 2008

Not Evaluated

Problem #

traumatized skin
tissue 2 to
episiotomy

Interrupted breast
feeding r/t infant
illness

Situational Low
Self-Esteem r/t
perceived failure at
life events 2 to
rape trauma

LEARNING OUTCOMES

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


constraints with regards to the implementation of interventions. It was not
that easy specially that what I am dealing with are lives, lives through
which if jeopardized, can either put me in an obnoxious situation or be
blameworthy for any complications.

Three days of multi-tasking and time management, the OBNURSERY ward exposure has taught me how to appropriately handle
pregnant and post partum women. The idea of caring for mothers and
newborns which is not in my lineage is hard. Hard, because some of the
patients are uncooperative and non compliant. It isnt that smooth to
establish an interacting relationship specially that most of the patients
admitted in the institution has a low educational attainment. Therefore, I
cannot expect them to fully comprehend the instructions I have imparted.
However, it was a marvelous experience since I was exposed to various
kinds of maternal paragons and procedures which werent return
demonstrated yet. Fortunately, there is our clinical instructor who
persistently supervised us and assisted us to make it through with just
minimal errors.

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


an individual case study. Adding to that is the fear of making a physiologic
structure of my opted case. One false move and I am screwed. I have
learned to thoroughly assess my patient to comply with the requisites.
Also, I have acquainted myself with regards to establishing rapport with
my patient to have a trusting relationship. Some patients do not totally
disclose themselves because they may find it privacy invading. I have

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


towards the patient; to respect and accept their beliefs and values without
judging them; to communicate with them therapeutically; to be accurate
and systematic when it comes to charting to avoid errors and reprimands.
Basically, its the feeling of confidence you have in yourself that will
facilitate accomplishment and error-free implementation of nursing care. If
you are confident enough to perform the procedures, then the client will
develop trust and confidence to you. The nurse has a lot of responsibilities
to take in, thus, confidence is a very important factor.

The exposure wasnt centered mainly to rendering care. It


was

also

focused

to

building

and

developing

intrapersonal

and

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


with the environment is a humongous task! Its not that easy. But mingling
with other people helps you identify your strength and weaknesses, and it
aids in modifying what is somehow negative in our attitudes. To sum this
all up, it was a SUCCESS! Thanks be to GOD.

The next time that Ill render care and perform procedures, I
will try to do my best to attain satisfaction and accomplishment.

ACKNOWLEDGEMENT

The materialization of this case study wouldnt be possible


without the aid of the following folks:

To the Almighty Father for the strength given in realizing and


fulfilling the duties and the study; to beloved parents who have always
been supportive all throughout the start of the duty until the end, the toils
and efforts; to dear comrades and colleagues who have been extending
all out help during the rough scenarios, specially to Miss Sheila Marie
Adorador for aiding me in realizing the case study; and to my groupmates
for

the

overwhelming

support,

help

and

camaraderie,

for

being

cooperative and indulging, that helped me augment my learning and


somehow sharpened my skills.

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


Ritchie Pelos, for simplifying what used to be incomprehensible, tricky and
complicated concepts, for assisting us in the various procedures we have
performed, and for being kind to us despite our immaturity

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