CONTENT

NO TITLE PAGE

1 Acknowledgement 2

2 Introduction to uterus 3-4

3 Overview of Spontaneous 5
vaginal delivery (SVD)
4 Sign and symptom of labour 6

5 Physiology of labour 7

4 Case 8-13

 Real case

 Reference A 14-20

 Reference B 21-26

5 Discussion 27-28

29
6 Conclusion

7
Reference 30

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 ACKNOWLEGEMENT

The internship opportunity I had at Labor Room, Hospital slim river was a great chance for
learning and professional development. Therefore, I consider myself as a very lucky individual as
I was provided with an opportunity to be part of it. I am also grateful for having a chance to meet
so many wonderful people who led me though this internship period.

Bearing in mind previous I am using this opportunity to express my deepest gratitude and special
thanks to our coordinator instructor Encik Mahidzir Bin Hassan, Encik Wahyudin Bin Ahmad and
our lecturers who in spite of being extraordinary busy with their duties, took time out to hear, guide
and keep me on the correct path and allowing me to carry out my project at their esteemed
organization, extending during the training and giving necessary advices and guidance and
arranged all facilities to make life easier.

It is my radiant sentiment to place on record my best regards, deepest sense of gratitude to Hospital
Slim River and all the Medical staff at Labor Room for their careful and precious guidance which
were extremely valuable for my study both theoretically and practically.

I express my deepest thanks to Madam Suriyana Binti Yasinrudin and his family to giving me
correct information about the patient and help me to carry out my project.

Last but not least, I would like to thank my batch mates who guide me on the correct path and
giving advices during carry out my project.

I perceive as this opportunity as a big milestone in my career development. I will strive to use
gained skills and knowledge in the best possible way, and I will continue to work on their
improvement, in order to attain desired career objectives. Hope to continue cooperation with all of
you in the future.

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 INTRODUCTION OF UTERUS

Uterus, also called womb, an inverted pear-shaped muscular organ of the female reproductive
system, located between the bladder and rectum. It functions to nourish and house the fertilized
egg until the unborn child, or offspring, is ready to be delivered. The uterus has four major regions:
the fundus is the broad, curved upper area in which the fallopian tubes connect to the uterus; the
body, the main part of the uterus, starts directly below the level of the fallopian tubes and continues
downward until the uterine walls and cavity begin to narrow; the isthmus is the lower, narrow neck
region; and the lowest section, the cervix, extends downward from the isthmus until it opens into
the vagina. The uterus is 6 to 8 cm (2.4 to 3.1 inches) long; its wall thickness is approximately 2
to 3 cm (0.8 to 1.2 inches). The width of the organ varies; it is generally about 6 cm wide at the
fundus and only half this distance at the isthmus. The uterine cavity opens into the vaginal cavity,
and the two make up what is commonly known as the birth canal.
Lining the uterine cavity is a moist mucous membrane known as the endometrium. The lining
changes in thickness during the menstrual cycle, being thickest during the period of egg release
from the ovaries. If the egg is fertilized, it attaches to the thick endometrial wall of the uterus and
begins developing. If the egg is unfertilized, the endometrial wall sheds its outer layer of cells; the
egg and excess tissue are then passed from the body during menstrual bleeding. The endometrium
also produces secretions that help keep both the egg and the sperm cells alive. The components of
the endometrial fluid include water, iron, potassium, sodium, chloride, glucose (a sugar), and
proteins. Glucose is a nutrient to the reproductive cells, while proteins aid with implantation of the
fertilized egg. The other constituents provide a suitable environment for the egg and sperm cells.

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The uterine wall is made up of three layers of muscle tissue. The muscle fibres run longitudinally,
circularly, and obliquely, entwined between connective tissue of blood vessels, elastic fibres, and
collagen fibres. This strong muscle wall expands and becomes thinner as a child develops inside
the uterus. After birth, the expanded uterus returns to its normal size in about six to eight weeks;
its dimensions, however, are about 1 cm (0.4 inch) larger in all directions than before childbearing.
The uterus is also slightly heavier and the uterine cavity remains larger.
The uterus of a female child is small until puberty, when it rapidly grows to its adult size and
shape. After menopause, when the female is no longer capable of having children, the uterus
becomes smaller, more fibrous, and paler. Some afflictions that may affect the uterus include
infections; benign and malignant tumours; malformations, such as a double uterus; and prolapse,
in which part of the uterus becomes displaced and protrudes from the vaginal opening.

OVERVIEW OF SPONTANEOUS VAGINAL DELIVERY

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Vaginal delivery is the method of childbirth most health experts recommend for women whose
babies have reached full term. Compared to other methods of childbirth, such as a cesarean
delivery and induced labor, it’s the simplest kind of delivery process.

A spontaneous vaginal delivery is a vaginal delivery that happen on its own, without requiring
doctors to use tools to help pull the baby out. This occurs after a pregnant woman goes through
labor. Labor opens, or dilates her cervix to at least 10 centimeters. Labor usually begins with the
passing of a woman’s mucous plug. This is a clot of mucous that protects the uterus from bacteria
during pregnancy. Soon after, a woman’s water may break. This is called a rupture of membranes.
The water might not break until well after labor is established, even right before delivery. As labor
progresses, strong contractions help push the baby into the birth canal.

The length of the labor process varies from woman to woman. Women giving birth for the first
time tend to go through labor for 12 to 24 hours, while women who have previously delivered a
child may only go through labor for 6 to 8 hours.

These are the three stages of labor that signal a spontaneous vaginal delivery is about to occur:

1. Contractions soften and dilate the cervix until it’s flexible and wide enough for the baby to
exit the mother’s uterus

2. The mother must push to move her baby down her birth canal until it’s born

3. Within an hour, the mother pushes out her placenta, the organ connecting the mother and
the baby through the umbilical cord and providing nutrition and oxygen.

SIGN AND SYMPTOMS OF LABOUR

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Lightening

 Movement of fetal head deeper into pelvis causing observable drop in abdomen

 Weeks to hours from onset.

Bloody show

 Bloody or brown discharge-the mucus plug of the cervix being released

 Days to hours from onset

Ruptured membranes

 Watery breaking

 Labour within 24 hours or induced

Contraction

 Labour begins when the cervix is effaced and 3-4cm dilated

 This usually coincide with regular contraction.

PHYSIOLOGY OF LABOUR

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1) Stages of Labour

 1ST stage

- Onset of labour until complete cervical dilation

 2nd stage

- Complete dilation until delivery of infant

 3rd stage

- Delivery of infant until delivery of placenta

2) 3 P’s of labour

 Power: force generated by uterine contractions

- Can be measured externally (Adequate considered 5 contractions in 10 minutes)

 Passenger: Variables affecting fetus include:

- Size of fetus

- Lie

~ Transverse, Longitudinal, Oblique

-Presentation

~Vertex, Breech, Shoulder, Compound

- Position
~Occiput anterior and posterior, Transverse
-Station
~Degree of descent in relationship of fetal head and ischial spines
~Number of foetuses
 Pelvis
- Delivery affected by bony pelvis and soft tissues including cervix and pelvic floor
musculature, difficult to assess adequate pelvis via imaging or clinical measurements
CASES

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 REAL CASE
A) Patient History
Real case I studied is spontaneous vaginal delivery (SVD). Patient name, Madam Suriyana Binti
Yasinrudin (RN 5906), Malay and 23 years old women came to Labor room from Ward 3 on 25
July 2018 at 8.00 am for the delivery. She accompanied by her husband. The chief complaint made
by this patient is leaking of liquor. Next, the history of presenting complaint made by this patient
is having 3 contraction within 10 minutes and 43 seconds and have a good fetal movement. After
had a conversation with this patient, we get to know that she does not have any past medical and
surgical history.

FAMILY TREE

Diabetes
Hypertension Mellitus

Nil
Husband PATIENT
Nil

Based on patient’s family history, we can know that this patient have parents and 1 sibling. This
patient also informed that her father and mother have hypertension and diabetes mellitus
respectively. At the same time, this patient said she was pregnant for the first time (primigravida)
and her husband was 26 years old.

From the drug history, we can know that this patient do not have any drug allergic. While the social
history of this patient shows that this patient is a housewife and not a smoker or alcoholic
consumer.

B) Physical examination

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During general examinations, this patient is look alert, pink, conscious and good hydration.

The vital sign of this patient is,

Initial Current
Blood pressure (BP) 116/76 mmHg 122/85 mmHg
Pulse rate (PR) 76/min 98/min
Respiration rate (RR) 20/min 21/min
Body temperature (BT) 37 degree Celsius 37.5 degree Celsius
Pain score 5/10 7/10

Cardiovascular system is shown dual rhythm no murmur (DRNM) and S1S2 heard clearly. When
auscultate the lungs, air entry show equal and clear. During palpitation, stomach shows in soft,
non-tender, no mass condition and bowel sound active also found in stomach. Other physical
examination found in her body is back pain and abdominal pain caused by contraction. No edema
and varicose vein seen on both feet.

C) Differential diagnosis

The differential diagnosis that can made is spontaneous vaginal delivery (SVD), induced vaginal
delivery (IVD), caesarean and assisted vaginal delivery (AVD).

D) Investigation

After undergo the patient’s history, physical examination and finding differential diagnosis, next
doctor carry out some laboratory and radiology investigation. For laboratory test, full blood count
(FBC) were taken. The result is as shown below:

Full blood count Result Normal range

Haemoglobin (Hb) 11.4 g/dl 13-18

White blood count (WBC) 10.40x10^3/UL 4.0-10.0

Platelet count 371x10^3/UL 150-450
Total red cell (TRC) 4.89x10^6/UL 4.5-5.5
Result for Urine FEME is as shown below

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 UFEME Result
Leucocyte Negative

Nitrite Negative
Urobilinogen Normal
pH 6.5
Protein Negative
Blood Negative
Ketones Negative
Bilirubin Negative
Glucose Negative

Beside this laboratory investigations, doctor carry out other laboratory tests like high vaginal swab
culture and sensitivity which growth does not obtain. Next is urine culture and sensitivity. This
test show non pathogen bacterial isolated.

Other than this, ultrasound test and cardio tocography of foetus were carry out for radiology test.
Cardio tocography (CTG) were carry out to listen the heart rate of foetus.

E) Diagnosis

Spontaneous vaginal delivery (G1P0 38/52+ 4/7 (Primigravida))

F) Treatment and management

Initial management

The initial management done by the doctor in Ward 3 is asking some questions about the patient’s
chief complaint and history of presenting complaint. After investigate, we know that this patient
came to ward 3 due to leaking of liquor. Before moved to labor room, medical staff checked
patient’s vital signs include blood pressure, respiration rate, pulse rate, body temperature and pain
score. Before move to labor room, patient admitted to ward 3 for the observation.

Ward management

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The routine ward management done to this patient is taking cardio tocography (CTG), and plot
patograph, doing bed making in the morning, checking patient’s vital sign 4 hourly, give
medication to the patient in correct dosage based on doctor’s order. Other routine ward
management is observing the branula intact of this patient to avoid from occurring bleeding and
strict input and output I/O charting. Not only that, other routine ward management is giving nursing
care and always observe this patient rest on bed.

While the specific ward management send this patient to labour room for artificial rupture of
membrane and for delivery. Other specific management is inserting Foley catheter to mother
before delivery to empty the bladder, monitoring blood sugar level 4 hourly, encourage mother to
breast feed her baby, give an oxytocin vaccines to mother and give BCG and Hepatitis B vaccines
to baby after delivered.

Post-Operative Management

 Uterus contracted and refracted well. No active per vaginal bleeding seen.

 Catheter in out done with 100ml of clear urine.

 Placenta delivered. Membrane and cortiledon complete

 Blood sample is taken from umbilical cord for G6PD and thyroid stimulating (TSH)
hormone test

 Perineum inspected intact

 Episiotomy sutured and repaired with safil 2/ox2

 Health care education is given

 Baby at birth vigorous, active and good crying

 Cord clamped and cut

 Regime placenta is checked and vulva swabbing done

Pharmacological treatment

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Drugs Generic name Trade name Dose Indication
IM Pethidine Pethidine - Adult: 0.5-2mg/kg Moderate to
75mg PRN HCL 50 mg/ml SC or IM every 3-4 severe acute
injection hours if necessary pain
IM Phenergen Promethazine PHENERGEN By deep IM Pre and
25mg PRN Adult: 25-50mg, postoperative,
maximum 100mg. or obstetric
Maximum 100mg sedation
-Prevention and
control of
nausea and
vomiting
T. Paracetamol Paracetamol PANADOL Adult: 500-1000 Mild to
1g TDS 500mg tab Tablet mg every 4-6 hours, moderate pain
maximum of 4g and pyrexia
daily
Tramal 50mg Tramadol HCL TRAMAL Adult: IV/ IM/ SC Moderate to
TDS 50mg/mℓ 50-100mg (IV severe acute or
Injection injection over 2-3 chronic pain
minute or IV (eg. post-
infusion). Initially operative pain,
100mg then 50- chronic cancer
100mg every 4-6 pain and
hours. Maximum: analgesia
400 mg daily.

G) Advice

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 Eat medications followed by the dosage that has been prescribed by doctor

 Drink plenty of water

 Do simple exercise

 Take plenty of rest

 Take care personal hygiene to prevent infection

 Eat healthy and vitamin rich diet

 Give breastfeeding to the baby. Exclusive breastfeeding for 1st 6 months

 Take an immunization of the baby like BCG and Hepatitis B properly as early as possible

 If there have any symptoms of jaundice appear, contact with a doctor.

REFERENCE A

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DEFINITION

According to the author Wayne R. Cohen from the book Labor and Delivery Care (2011) said
labor is the physiological process by which he gravida uterus evacuates its contents at or near term.
It requires a coordinated sequence of periodic myometrial contractions, which cause progressive
cervical dilatation and fetal descent through the birth canal. This simple descriptive definition is
accurate, but belies the complexity of the labor process, which is a biochemical, physiologic, and
mechanical masterwork that, despite centuries of investigation, we understand incompletely.

TERMINOLOGY

Gravidity refers to a pregnancy regardless of its duration. A gravida is a pregnant woman. She is
gravid, i.e., pregnant. A primigravida is pregnant for the first time; a nulligravida has never been
pregnant. A multigravida has been pregnant more than once.

Parity refers to the completion of viable pregnancy. Viability is defined for obstetric purposes as
one of sufficient duration to deliver a fetus weighing at least 500g or one of gestational age of 20
weeks or more. A primipara is a women who has had one pregnancy that resulted in a viable child.
Although the term primigravida and primipara are not synonymous, they are often erroneously
used as if they were interchangeable. A nullipara is a primigravida or multigravida who has not
yet delivered a viable infant. A multipara is a woman who has had two or more viable deliveries.

Parity involves deliveries by any route. Thus, a woman who has had three term cesarean deliveries
is a multipara. Nevertheless, the labor of parous women who have never had a vaginal delivery
tend to conform to criteria established for nulliparas. That is to say, they behave functionally in
term of the course of labor as if they were nulliparars. Moreover, the number of infants carried
during any given pregnancy is not a relevant factor in determining parity (or gravidity). A woman
who delivers twins or triplets in her first pregnancy, for example, is still considered a primipara.

STAGES

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  THE FIRST STAGES

When labor begins, uterine contractions are usually 5-15 minutes apart. As labor progresses, they
generally become stronger and more frequent, often occurring at intervals of 2-3 minutes by late
first stage. Each contraction begins before the patient perceive pain. During a contraction, the
uterus rises forward in the abdomen, pushing against the anterior abdominal wall. (As a
consequence in a very thin patient you may sometimes see the round ligaments stand out sharply.)
The movement of the uterine wall and overlying abdominal wall allows assessment of contractions
using an external tocodynamometer, an electromechanical device that detects changes in the
abdominal contour.

We should learn to palpate contractions and to judge their intensity by the hardness of the
fully contracted uterine wall. During contractions, the uterus becomes rigid. On vaginal
examinations, you can often feel the cervix tensing, in response to the force imposed upon it by
the fetal head countering the tension applied to the passive fibrous connective tissue of the lower
uterine segment and cervix by the powerful contraction of the upper uterus. If the membranes are
still intact, you may feel them bulging tensely toward, or even beyond, the external os.

The uterus may be considered to have two functionally distinct parts, an upper or
contracting portion and a lower or dilating portion. The anatomic delineation of these parts is the
physiologic retraction ring. When a contraction occurs, the amniotic fluid and the fetal head are
pressed down toward the cervix. At the same time the membranes are impelled pouch-like into the
cervical canal, pushing out the plug of mucus that had occupied it during the pregnancy. Once the

15
cervix is completely effaced only the external os remains. Dilatation continues until the external
os is opened so wide that it is flush, or nearly os, with the vagina. Dilation is now complete, the
cervix having retracted around to the widest diameter of the presenting part. From this point on,
descent is unimpeded and the fetus is able to pass into the vagina and ultimately deliver.

Once the cervix is completely dilated, it is pulled up or retracted in response to the force exerted
by the active upper segment until it is often out if reach of your examining fingers. Effacement of
the cervix and dilatation occasionally occur simultaneously, especially in multiparas. After the
cervix is fully opened, the first stage of labor has ended and the second stage begins. Coincident
with these changes toward the end of the first stage, you will observe the fetal head begins its
descent through the pelvis.

 THE SECOND STAGES

After full cervical dilatation has been reached, descent begins in earnest (if it has not already begun
late in the first stage). Contractions tend to grow stronger and become quite frequent, usually
recurring every 2-3 minutes, occasionally more frequently. Because the cervical end of the uterus
is moored to the pelvis by the cardinal and uterosacral ligaments, shortening of the contracting
myometrium in conjunction with diaphragmatic and abdominal wall expulsive efforts and
simultaneous thinning of the lower uterine segment pushes the fetus downward onto the pelvis
until it is born. Contractions of the round ligaments, which occur synchronously with those of the
upper uterine segment, may contribute to fetal descent.

As the vagina is distended by the descending presenting part, your patient will have the
sensation that there is something in the pelvis she must expel. While this urge to bear down usually
heralds the onset of the second stage, it may be delayed for some time, particularly if the head
remains relatively high in the pelvis. Conversely, it may occur prior to full dilatation if the head is
deep in the pelvis toward the end of the first stage. The urge to bear down should be actively
discouraged until the cervix has dilated completely before full cervical dilatation offer no benefit
in advancing labor, it will only serve to exhaust the gravida in the process. Remember, with
epidural anesthesia women may not experience the urge to push out the fetus.

In most circumstances, to bear down, the parturient fixes her chest in inspiration, closes
the glottis, braces her feet, and by powerful action of the abdominal and diaphragmatic muscles

16
drives the fetal head toward the perineum. During the contraction the uterine wall is felt to be
board-like, and may be tender. The maternal pulse becomes rapid, not infrequently in the 120-
140bpm (beats per minutes) range, and sometimes higher.

The descending fetal head sometimes presses on the sacral and obturator nerves, explaining
the pains radiating into the legs and back that your patient may experience. These are more likely
to occur when the head is descending in an occiput posterior position.

As descent progresses, generally pressure is felt on the rectum. Feces in the lower bowel
are forced down by the advancing head and may be evacuated. As the head reaches the pelvic
floor, you will observe the perineum distend with each contraction as the fetal head is forced
against it. Eventually, the anus begins to open and hemorrhoids, if present, swell. The perineum
lengthens and thins out. Soon the labia are seen to part during the height of a contraction, exposing
the wrinkled scalp of the fetus. As the contraction subsides, the elastic pelvic floor forces the head
back.

With each succeeding contraction you will observe the perineum bulge more expansively.
The anus opens wider, the labia separate further, and a larger segment of the scalp becomes visible.
The introitus becomes a tense ring around the presenting part as it further distends the perineum,
a situation called crowning. As the contraction disappears, the head will recede somewhat. In the
intervals between contractions, the woman lies back exhausted, resting.

Once the pelvic floor has relaxed sufficiently, the head rests persistently on the vulva. The
patient often feels a burning or tearing sensation (even if there is no visible tissue damage) and
feels an overwhelming urge to expel the fetus. Now, by supreme exertion, coupled with great
emotional effort and powerful muscular contractions, the head is forced out, the occiput emerging
from behind the pubis, followed in succession by the forehead, face, and chin rolling over the
perineum. The nape of the fetal neck stems beneath the symphysis pubis. After this, there may be
a pause for a few seconds or even minutes. Then the contractions are renewed. The shoulders are
delivered, generally the anterior shoulder emerging first under the symphysis pubis if the mother
is sitting or lying with her abdomen uppermost. If she is in the lateral position, the posterior fetal
shoulder usually delivers first. After the shoulders, the trunk and lower extremities emerge in one
long hard expulsive effort. A little blood and the rest of the amniotic fluid are discharged.
Abdominally, the uterus rapidly contracts so that you can palpate its fundus at the level of the

17
umbilicus. The second stage has ended. The uterus must still expel the placenta and the
membranes.

 THE THIRD STAGE

The contractions of the third stage of labor help separate the placenta and promote its descent.
Your patient may feel regular contractions every few minutes. Occasionally, these are perceived
as quite strong. Within several minutes to a half hour you will feel the uterine corpus rise higher
in the abdomen and change in shape from discoid to globular. At the same time, you will observe
the cod advance a few centimeters from the introitus. Some increase in vaginal bleeding occurs at
this time. These sign indicate that the placenta has become separated from the uterine wall.

After this occurs, the placenta is usually expelled spontaneously in a few minutes by the
combined efforts of abdominal and uterine muscles. The placenta usually emerge like an everted
umbrella and draws the membranes after it, peeling them off the uterine wall. Sometimes it slides
out without doubling up, the lower portion appearing first. Some blood is discharged with the
placenta. Once it delivers, you will feel the uterus contract promptly into a hard mass.

 THE FOURTH STAGE

The uterus, emptied of its contents, now contracts powerfully, a mechanism that reduces
postpartum blood loss. These contractions are sometimes quite painful for the first 30-60 minutes
after delivery. Uterine contraction also squeezes venous blood from the uterus into the maternal
circulation, where it helps compensate for the blood volume lost at delivery, which is commonly
300-500 mL. You should carefully inspect the perineum, vagina, and cervix after delivery. Repair
of lacerations or episiotomy should be accomplished at this time.

Some women begin nursing their newborn right after delivery. This process releases
oxytocin, which enhances uterine contractions that serve further to reduce blood loss. Nursing and
handling the newborn also helps initiate the complex process of parent-infant bonding. You will
wish to ensure that the uterus is well contracted, that ongoing blood loss is appropriately small,
and that she has no troublesome symptoms. This is also an opportunity to encourage and assist
with attempts to nurse the baby, and a time to review the events of labor with the new mother. The
latter is especially important if there have been any complications that requires explanations. But
even normal events and procedures deserve clarification.

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MEDICATION
Mother:
 Amoxicillin 500mg. 3X a day
 Mefenamic Acid 500mg. 3X a day
 Ferrous Sulfate + Folic acid- once a day
Baby:
 Vitamin KBCG
 Hepatitis B
 Erythromycin
 Ophthalmic Ointment

INDICATION

 Complete dilation

 Absence of contraindication

CONTRAINDICATION

 Active herpes simplex lesions or prodromal (warning) symptoms

 Certain malpresentations (eg. nonfrank breech, transverse, face with mentum posterior)

 Complete placenta previa

 Previous vertical uterine incision or transfundal uterine surgery

 The mother does not wish to have vaginal birth after cesarean delivery.

COMPLICATION

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 Labour and shoulder dystocia

 Precipitous delivery

 Breech presentation

 Post-partum hemorrhage

 Meconium

 Cord prolapse

 Endometritis

 Vacuum assisted delivery

REFERENCE B

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DEFINITION

According to the author Dale A.Patterson from the article American family Physician (august
2008) said Labour is defined as the onset of regular contractions and cervical change. It is
traditionally divided into three stages. The first stage encompasses the onset of labour to the
complete dilatation of the cervix, and is subdivided into latent and active phases. The active phase
begins when the rate of cervical dilatation accelerates, which occurs at 4 cm on average. The
second stage consists of the time from complete dilatation of the cervix to delivery of the infant.
The third stage is complete at the delivery of the placenta. The original labour curves were plotted
by Friedman in the 1950s and are the traditional basis for defining prolonged labour patterns.

STAGES

 FIRST STAGE OF LABOR

Patients in labour are usually admitted to the hospital during the first stage of labor. It is important
to differentiate between the active and latent phases because women admitted in latent labor tend
to spend more time in the labor ward and have more interventions than those whose admission is
delayed until the active phase. When a patient is admitted during the latent phase, physicians
should set reasonable expectations for labor progress to avoid unnecessary interventions and
anxiety. In GBS-negative women who are at term, admission to the labor ward should be delayed
until the active phase of labor begins.

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 The most common intervention in the first stage of labor is pain control. There are
numerous nonpharmacologic methods available to ease the discomfort of labor and improve the
experience, including positioning, ambulation, massage, aromatherapy, and acupressure.
However, there are limited published data available on these methods. One Cochrane review
showed that acupuncture and hypnosis may be beneficial for pain control. Another Cochrane
review found that women should have continuous support throughout labor and delivery to
decrease the need for epidural analgesia and operative delivery and to improve the childbirth
experience.

Pharmacologic pain control is often used during labor; the most common interventions are
intravenous narcotics and epidural analgesia. Epidurals have been shown to effectively decrease
pain during labor, but may lead to an increase in instrumental vaginal delivery. Instruments may
be employed more often because epidural analgesia lengthens the second stage of labor, prompting
intervention for a perceived dystocia. Discontinuing epidurals late in labor decreases pain control
and does not decrease the need for instrumental delivery. Patients who choose epidurals do not
increase their risk of having a cesarean delivery. Physicians should expect patients who receive an
epidural to have adequate pain control and to progress less rapidly than predicted by the Friedman
curve. Understanding this delay can prevent unnecessary interventions.

Fetal heart rate monitoring during labor has become common; it was used in 85 percent of
deliveries in 2002. Monitoring is used to determine the well-being of the fetus. The high false-
positive rate of fetal heart rate monitoring is well recognized, and its continuous use increases
cesarean and operative vaginal deliveries without decreasing overall perinatal mortality or the
incidence of cerebral palsy. The addition of fetal pulse oximetry does not decrease the need for
cesarean delivery, and there is no evidence to support its use at this time. Fetal electrocardiogram
(ECG) monitoring is a newer technology that has shown potential because it reduces acidosis and
the need for operative vaginal delivery when used as an adjunct to continuous fetal heart rate
monitoring. Fetal ECG monitoring requires internal electrodes and ruptured membranes to record
waveforms. Further study needs to be done before the use of fetal ECG can be recommended.

 SECOND STAGE OF LABOR

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During the second stage of labor, the fetus descends through the maternal pelvis and is ultimately
expelled. Tremendous stress is placed on the passageway, often resulting in trauma to the
genitourinary tract, most commonly the perineum. Spontaneous tears that require suturing occur
in approximately one third of women, and anal sphincter tears occur in less than 1 percent.

Reduction in perineal trauma is desirable because affected women have an increased risk
of long-term perineal pain, long-term dyspareunia, urinary problems, and fecal incontinence.
Antenatal perineal massage can reduce the need for laceration repair or episiotomy, and can reduce
prolonged pain in women without prior vaginal delivery. Although these benefits were modest,
the technique has no known deleterious effects and may be beneficial in some primigravidas.

Maternal pushing methods can impact second-stage outcomes. Coached pushing with sustained
breath holding (closed glottis pushing) results in a slightly shorter second stage (by 13 minutes)
compared with spontaneous exhalatory pushing (open glottis pushing). Delayed pushing (i.e.,
waiting until the maternal urge to push is strong instead of encouraging pushing immediately at
complete cervical dilatation) prolongs the second stage of labor, but shortens the duration of
pushing and results in an increased number of spontaneous deliveries. Varying techniques of
pushing have not been shown to impact perinatal mortality or perineal trauma.

There is conflicting evidence about maternal position in the second stage of labor. Upright or
lateral position may allow more effective pushing and may be preferred by some patients to the
supine position with stirrups. Because good evidence is lacking to support one particular birthing
position, the patient should be allowed to deliver in the position most comfortable for her.

Delivery techniques vary by region and physician. Attempts have been made to determine the best
ways to guide the process of labor. Studies comparing the “hands poised” technique (i.e., not
touching the baby's head or supporting the mother's perineum until delivery of the head) with the
“hands on” technique (i.e., applying pressure to the baby's head during delivery and supporting the
mother's perineum) have shown no major differences in outcomes, including rates of perineal
trauma and tears. Patients delivering via the “hands poised” technique were less likely to have
episiotomies, but had a slightly higher risk of perineal pain after delivery. Given the subtle
differences in outcomes, either approach to delivery is appropriate.

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Episiotomy, an intentional incision in the perineum. Recently, the idea of restrictive episiotomy
has gained acceptance. Compared with routine use, limiting episiotomy to use when indicated
increases the likelihood of maintaining an intact perineum and decreases healing complications.
Although restrictive episiotomy increases the risk of anterior perineal trauma, there is no
significant difference in risk of third-degree tears, dyspareunia, or urinary incontinence compared
with routine episiotomy. Benefits of restrictive episiotomy are seen with median and mediolateral
episiotomy. The practice of routine episiotomy should be abandoned.

Nonsuturing of the perineal skin in first- and second-degree tears and episiotomies results in less
pain for up to three months after delivery and less dyspareunia at three months after delivery. Non
suturing of the muscle layers is not recommended because of poorer wound healing at six weeks
postpartum. When repair of the perineum is required, use of a continuous, knotless technique is
preferred over interrupted suturing. The knotless technique reduces short-term pain and the need
for postpartum suture removal without compromising wound healing or long-term
outcomes. Repair with absorbable synthetic suture is preferred to catgut. Synthetic suture
decreases analgesic use and decreases dyspareunia at 12 months.

 THIRD STAGE OF LABOR

During the third stage of labor, the uterine muscle must contract adequately to slow maternal blood
loss once the placenta separates from the uterine wall. A prolonged third stage of labor, which is
diagnosed after 30 minutes if spontaneous placental delivery does not occur, may require further
intervention.

Postpartum hemorrhage is defined as excess blood loss from the uterus (more than 500 mL) during
and after delivery. Causes of postpartum hemorrhage include uterine atony, retained tissue, trauma
to the genital tract, and coagulopathies.

Active management of the third stage of labor includes administration of an oxytocic agent after
delivery of the anterior shoulder, early cord clamping, and controlled cord traction. This
management decreases maternal blood loss, risk of postpartum haemorrhage, length of the third
stage, and the need for blood transfusion. Despite an increase in maternal nausea and vomiting,
active management of the third stage is strongly encouraged. Placental cord drainage, which

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involves clamping and cutting the cord after delivery and then immediately unclamping the
maternal side (allowing blood to drain freely), decreases the length of the third stage of labor.

INDICATION

 Absence of contraindication

 Complete dilation

CONTRAINDICATION

 Complete placenta previa

 Herpes simplex virus with active genital lesions or prodromal symptoms

 Previous classic uterine incision or extensive transfundal uterine surgery

 Untreated human immunodeficiency virus infection

COMPLICATION

Complications occasionally arise during childbirth; these generally require management by an

obstetrician.

Non-progression of labor (long-term contractions without adequate cervical dilation) is generally

treated with cervical prostaglandin gel or intravenous synthetic oxytocin preparations. If this is
ineffective, Caesarean section may be necessary.

Fetal distress is the development of signs of distress by the child. These may include rising or
decreasing heartbeat (monitored on cardiotocography /CTG), shedding of meconium in the
amniotic fluid, and other signs.

Non-progression of expulsion (the head or presenting parts are not delivered despite adequate
contractions): this can require interventions such as vacuum extraction, forceps extraction and
Caesarean section.

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 DISCUSSION

SIMILARITY

Real case, Reference A and Reference B

Based on my case study, there have a few similarity I found in real case, Reference A and
Reference B. First similarity I found in this three cases is its definition. These three cases stated
labor is physiological process by which he gravida uterus evacuates its contents at or near term. .
It requires a coordinated sequence of periodic myometrial contractions, which cause progressive
cervical dilatation and fetal descent through the birth canal.

Next similarity I found from the real case and the references is the stages of labour. Author
Wayne R. Cohen and Dale A. Patterson form the reference A, B and real case said that there have
3 main stages of labour where stage 1, stage 2 and stage 3. In first stage encompasses the onset of
labour to the complete dilation of the cervix, and is subdivided into latent and active phase. During
active phase, the rate of cervical dilatation increases, which happens at 4cm on average. The second
stage is the stage where consist of the time from complete dilatation of the cervix to delivery of

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the infant. While the third stage is complete at the delivery of placenta.

Other similarity found from Reference A, B and real case is the indication and
contraindication of labour. Medical staff in real case and Reference A and B mentioned the
indication of labour is complete dilation. While the contraindication of labour is complete placenta
previa, active herpes simplex lesions or prodromal symptoms, untreated human immunodeficiency
virus infection and Previous vertical uterine incision or transfundal uterine surgery.

Next similarity from these three cases is the complication of the labour. Real case and these
two references mentioned the complication maybe faced by the mother after delivered is labour
and shoulder dystocia, breech presentation, post-partum hemorrhage which defined as an excess
blood loss from the uterus (more than 500 mL) during and after delivery. Other complication is
cord prolapse, meconium, vacuum assisted delivery and non-progression of expulsion for example
the head or presenting parts are not delivered despite adequate contractions.

As a conclusion, we can understand that the real case, Reference A and B are used same definition
of labour, stages, indication, contraindication and complications.

DIFFERENCE

Real case, Reference A and Reference B

Based on my case study, there also have a few difference found in this real case, Reference
A and Reference. First difference I found from these cases is the fourth stages of labour. Beside
first, second and third stages, there also have fourth stages of labour that introduced by author
named Wayne R. Cohen from Reference A. He said during fourth stage the uterus emptied of its
contents and contract powerfully. This can help to reduce the postpartum blood loss. At the same
time, this author mentioned theses contractions can be so painful for the first 30-60 minutes after
delivery. Some women begin nursing their newborn right after delivery during this stage. This
process releases oxytocin, which enhances uterine contractions that serve further to reduce blood
loss. But real case and author named Dale A.Patterson from reference B are not mentioned this
stages in their case.

Next difference is in term of medications. In term of pharmacology treatment I found

doctor in real case prescribed drugs like IM Pethidine 75mg TDS, IM Phenergen 25mg PRN,

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T.Paracetamol 1g TDS and Tramal 50 mg TDS for mother. While immunization BCG and
Hepatitis B are given to baby in real case. Not only that, author in Reference A used Amoxicillin
500mg TDS, Mefenamic Acid 500mg TDS and Ferrous sulfate + Folic acid OD for delivered
mother and prescribed vitamin KBCG, Hepatitis B, Erythromycin and ophthalmic ointment for
baby. But author named A.Dale Patterson from Reference B not stated any medication for mother
and baby.

As a conclusion, we can understand that the real case, Reference A and B are used different
pharmacology treatment for labour.

CONCLUSION

During our two weeks posting at Labor room, everyone should take case study, document and
present in comprehensive and systematic way with real situation to patient. By this way I also got
the chance to have case study in labor room. I gained knowledge in depth by comparing the care
with patient, I collected information from internet, doctors, ward sisters, nurses, lab, radiology and
record section and compared it with patient in real situation.

During my duty period in labor room, I provided her a holistic care, diversional therapy in very
aspects like physical, emotional, economical and socio-cultural view. I also gained the knowledge
about a spontaneous vaginal delivery (SVD) which occurs when a pregnant female goes
into labor without the use of drugs or techniques to induce labor, and delivers her baby in the
normal manner, without forceps, vacuum extraction or a cesarean section. Not only that, also
gained knowledge about the Medical Assistant theory and application in real situation. So this
spontaneous vaginal delivery (SVD) case, not only gives the cognitive domain but also provides
us the opportunity to develop psychomotor domain, which is very important in Medical Assistant
course, so the patient is the main source of conveying knowledge in practice.

Last but not least, I also got the chance to know more about spontaneous vaginal delivery (SVD),
its sign and symptom, investigation, treatment and prevention in different articles which help to

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gain my knowledge. Not only that, this case study also helped me to gain my communication skills
with patients. At the same time, I got the best chance to investigate this spontaneous vaginal
delivery (SVD) case in real situation.

REFERENCE

Best Practice in Labour and Delivery by Sir Sabaratnam Arulkumaran and Richard Warren (Year
2009)

Labor and Delivery Care (A Practical Guide) by Wayne R.Cohen and Emanuel A.Friedman (Year
2011)

DALE A. PATTERSON, MD, Family Medicine Residency Program at Memorial Hospital of

South Bend, South Bend, Indiana (American Physician family physician) year 1 August 2008

https://www.aafp.org/afp/2008/0801/p336.html

https://www.healthline.com/health/pregnancy/spontaneous-vaginal-delivery#4
https://www.aafp.org/afp/2008/0801/p336.html
https://www.acog.org/Womens-Health/Labor-and-Delivery
https://www.britannica.com/science/uterus
https://www.slideshare.net/meducationdotnet/spontaneous-vertex-delivery-normal-childbirth
https://www.slideshare.net/meducationdotnet/spontaneous-vertex-delivery-normal-childbirth

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http://americanpregnancy.org/labor-and-birth/first-stage-of-labor/
http://nursing-resource.com/normal-spontaneous-vaginal-delivery/
https://www.ncbi.nlm.nih.gov/pubmed/18711948
https://www.practo.com/health-wiki/normal-vaginal-delivery/152/article

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