Case-Study Final

THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”

College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
A CASE STUDY ON NORMAL SPONTANEOUS VAGINAL DELIVERY
In Partial Fulfillment of the Requirements in NCM- 104 RLE

A.Y 2021-2022
Presented to:
Ms. Myrrha Taganas, RN
Faculty of the College of Nursing
The College of Maasin
Presented by:
Sanchez, Hennie Vee G.
Maldo, Micah Joyce P.
BSN- II LEVINE
March, 2021
INTRODUCTION
A case of a 25-year-old woman, Mrs. B who was brought to the hospital by her mother
in law and reports that she has been in labor for 8 hours and that her membranes ruptured 3
hours ago. Upon arrival at the hospital, she had a strong contraction lasting 45 seconds and is
showing signs of labor. A quick check to detect signs/symptoms of life-threatening complications
have been completed and, finding none, quickly proceeded to physical examination to
determine whether birth is imminent. Although Mrs. B is not pushing, and has a bulging, thin
perineum.
EPIDEMIOLOGY
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.
General Objectives:
This study aimed to broaden the student’s knowledge for Normal Spontaneous
Vaginal Delivery by obtaining sufficient information which could serve as a guide for
student nurses who will be focusing on the same case and it is also designed to enhance
skills and attitudes in the application of nursing process and management of the
procedure.
Specific Objectives:
After thoroughly discussed the case presented, the nursing students shall be able to:
 To gain enough knowledge and understand the entire course of the procedure.
 To know the client’s personal data, her family profile, past health history, current
medical history, and physical assessment.
 To review the anatomy and physiology of the female reproductive system.
 To discuss the purpose of the procedure and its possible complication.
 To correlate the results of the diagnostic procedures to its normal values.
 To develop an effective nursing care plan in which the client may benefit
Questions:
1. What history will you include in your assessment of Mrs. B and why?
- Past obstetric history. It is important to know how many pregnancies the patient has
gone through/lost. Patients often forget about miscarriages and ectopic pregnancies,
and may also not mention previous pregnancies from another husband or boyfriend.
Mrs. B.’s antenatal records should be quickly checked for history of present pregnancy,
as well as obstetric and medical histories, with particular attention to problems and
treatments
2. What physical examination will you include in your assessment of Mrs. B and
why?
-You should perform the following elements of examination to guide further assessment
and help individualize care provision. Some findings may help determine stage/phase of
labor, or may indicate a special need/condition that requires additional care or a life-
threatening complication that requires immediate attention
-Mrs. B.’s respirations, blood pressure, temperature and pulse should be measured to
ensure normalcy/normal progress, and detect abnormal signs/symptoms.
Abdominal examination including assessment of:
 Surface of abdomen for presence of scars, which might indicate a previous C-section
or other uterine surgery
Uterine shape, which may indicate lie and/or uterine abnormality
Fundal height, which will helps confirm gestational age or indicate size-date
discrepancy
Fetal parts and movement,which may indicate multiple pregnancy
3. What laboratory tests will you include in your assessment of Mrs. B and why?
- A urinalysis and a CBC test because urinalysis is important to rule out a urinary tract
infection. Pregnant women are prone to urinary tract infections due to the progesterone
effect on the smooth muscle of the ureters and a complete blood count to identify and
prevent problems, a CBC may be done before pregnancy, if possible, at the beginning
of pregnancy, and one or more times during pregnancy. The first baseline results can
be compared to later values to look for changes that could indicate a health issue.
4. Based on these findings, what is Mrs. X's diagnosis (problem/need) and why?
- Mrs. B. has reached the second stage of labor, indicated by full dilation of the cervix
5. Based on your diagnosis (problem/need identification), what is your plan of care for
Mrs. B and why?
- Mrs. B. must not be left alone. She should receive on going assessment (e.g.,
maternal pulse and contractions every30 minutes, fetal heartrate every 5minutes) to
ensure that any problems or abnormalities in the condition of mother or baby or
progress of labor are detected early for immediate attention.
She should receive on going supportive care:
 A supportive, encouraging atmosphere that is respectful of Mrs. B’s wishes should be
established to provide emotional support.
 Mrs. B. should be made comfortable and encouraged to adopt a position for pushing
that is comfortable for her and aids in the descent of the fetus: semi-sitting/reclining,
squatting, hands and knees or lying on side.
 Mrs. B. should been courage to follow her own tendency to push: the intensity of her
contractions should regulate her efforts to push. She should be encouraged not to
6. Based on these findings, what is your continuing plan of care for Mrs. B and why?
Immediate new born care should be provided:
 Thoroughly dry baby and cover in clean, warm cloth.
 Clamp/tie and cut cord.
 Place baby in skin-to-skin contact on the mother's abdomen; encourage

breastfeeding.
Once Mrs. B.’s abdomen is palpated to rule out the presence of an additional
baby, the placenta should be delivered using active management of third stage of
labor:
 Administer oxytocin 10 units IM.
 Perform controlled cord traction.
 Deliver and examine the placenta
Placenta, cord, and membranes should be checked for completeness.
 Assess uterine tone and if necessary massage the uterus through the abdomen until
firmly contracted (Mrs. B. should also be shown how to massage her fundus to maintain
the contraction)
 Examine the vagina and perineum for lacerations or tears.
 Mrs. B. should be made comfortable (e.g., cleanse perineum, change bed linens).
 She and the baby should receive ongoing assessment every 15minutes for first 2
hours following birth (e.g., mother: blood pressure, pulse, fundus [for firmness], and
vaginal bleeding; newborn: respiration, warmth, color to ensure that any problems or
abnormalities in the condition of mother or baby are detected early for immediate
attention
I. NURSING HEALTH HISTORY

A. Biographic Data
Name: Mrs. B
Address: N/A
Age: 25
Gender: Female
Marital Status: Married
Occupation: N/A
Religious Orientation: N/A
Health Care Financing: N/A
Informant:
B. Chief Complaint:
Few hours prior to admission on the hospital the patient was already in labor for 8
hours that her membranes ruptured 3 hours ago. Upon arrival she was assessed
with bulging in her perineum
C. History of Present Illness:
N/A
D. Past History
The patient has no known allergy to any foods or drugs and has no history of
hypertension, diabetes mellitus or asthma
E. Family History
There was no known familial disease in their family
GORDON’S FUNCTIONAL HEALTH PATTERN
A. Health Perception and Health Maintenance Management Pattern
Patient is 25 yrs. Old, female and married. She was in labor for 8 hours and that her
membranes ruptures 3 hours ago before she was admitted in to the hospital. She had a
strong contraction lasting for 45 seconds and there is a bulging in her perineum which is
possibly cause by the pressure during her prolonged labor
B. Nutritional & Metabolic Pattern
Patient has complete meals (breakfast, lunch, and dinner) and has fluid intake of 8-10
glasses /day. She eats meats, vegetables and fruits.
C. Elimination Pattern
Bladder Habits:
She can void 3 to 4x a day without any pain felt
Bowel Habits:
She can defecate once a day with a formed stool
D. Activity-Exercise Pattern
During pregnancy the patient do exercise which can reduce backaches, constipation,
bloating and swelling. Boost your mood and energy levels. Help you sleep better.
E. Sleep-Rest Pattern
She has a good sleep-wake cycle. She usually sleeps 6-8 hours
F. Cognitive-Perceptual Pattern
She has no deficit in her sensory perception (hearing and sight) and she’s able to read
and write. She can hear and answer questions being asked. She is aware of the
conversation. She can see people that surrounds her.
G. Self-Perception and Self-Concept Pattern
According to her significant others, patient is a good mother and daughter. She is not a
smoker and doesn’t drink. She wants to reach her goals later on.
H. Role relationship pattern
Patient is very responsible. She always said that she wants to attain her goals or
dreams for her family
I. Sexually-reproductive pattern
Patient experienced sexual intercourse
J. Coping stress pattern
She said that, whenever she has a problem she shares it to the family and solve the
problems by herself and of course, listens to the advices of her family
K. Value-belief pattern
She is a roman catholic. She attended masses together with the family every Sunday.
DEVELOPMENTAL TASK
A. ERICKSON’S PSYCHOSOCIAL DEVELOPMENT TASK

YOUNG ADULT (19-40 years old)
STAGE BASIC ACTUAL
Intimacy vs. Isolation Positive: young adult Patient has a partner, they
needs to form intimate, lived together, she got
Age:19-40 years old loving relationship with pregnant in her 4th baby,
other people. Success and now she try her best to
leads to strong relationship be a good partner and a
good mother to her
Negative: failure to achieve upcoming baby.
results in loneliness and
isolation
HAVINGHURST’S DEVELOPMENTAL TASK

STAGE BASIC ACTUAL
Early adulthood - Selecting a mate The patient and her
Age 20-40 years old - Learning to live partner are already in their
with a partner 4th baby. All of her
- Starting a family previous pregnancies/
- Rearing children deliveries are
- Managing a uncomplicated and now
home they’re getting ready for
their 4th one
DEFINITION OF TERMS
1.
Normal Spontaneous Vaginal Delivery (NSVD)
A normal spontaneous vaginal delivery (NSVD) 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.
2.
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 happens 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.
3.
Normal spontaneous vaginal delivery is when a woman goes into labor without the aid
of any labor inducing drugs or methods, and is able to deliver the baby without requiring
a doctor’s aid through cesarean section, vacuum extraction, or with forceps, this is
known as a normal spontaneous vaginal delivery (NSVD).
ETIOLOGY
PREDISPOSING RATIONALE ACTUAL JUSTIFICATION

FACTORS
Sex: Female Only females are able to Patient is Present
get pregnant because of female
their reproductive
system, it has uterus
which is suitable for the
fetus to live and develop
until the time of delivery.
Age: 13 and Females who belongs to Patient is now Present
above reproductive age 25 years old.
(puberty age – 13 years
and above) are the one
who is already able to be
pregnant and those who
are already ovulating
PRECIPITATING RATIONALE ACTUAL JUSTIFICATON

FACTORS
Coitus Intercourse allows the Patient had Present
delivery of the sperm coitus with her
into the cervical canal husband
and travels to the
fallopian tube (isthmus)
to meet the egg and be
fertilized
Fertility During fertile days, Patient had Present
there is a release sexual
mature of ovum and is intercourse
proliferation on the with her
basal area of the partner during
uterine lining wherein fertile days.
there’s sufficient
amount of blood and is
suitable for fetal growth
ANATOMY AND PHYSIOLOGY
During labor, the role of the cervix must change from maintaining the pregnancy (by keeping the
uterus closed) to facilitating delivery of the baby (by dilating, or opening, enough to allow the
baby through). The fundamental changes that occur near the end of the pregnancy result in a
softening of the cervical tissue and thinning of the cervix, both of which help prepare the cervix.
True, active labor is considered to be underway when the cervix is dilated 3 centimeters or
more. Eventually, the cervical canal must open until the cervical opening itself has reached 10
centimeters in diameter and the baby is able to pass into the birth canal. As the baby enters the
vagina, your skin and muscles stretch. The labia and perineum (the area between the vagina
and the rectum) eventually reach a point of maximum stretching. At this point, the skin may feel
like it’s burning. Some childbirth educators call this the ring of fire because of the burning
sensation felt as the mother’s tissues stretch around the baby’s head. At this time, your
healthcare provider may decide to perform an episiotomy.
SYMPTOMALOGY
SYMPTOMS RATIONALE ACTUAL
Strong contractions These contractions cause ✔
the upper part of the uterus
to tighten and thicken while
the cervix and lower
portion of the uterus
stretch and relax, helping
the baby pass from inside
the uterus and into the
birth canal for delivery.
Fully dilated cervix The cervix has ✔
opened completely in
preparation for childbirth.
Rupture of amniotic sac Caused by a natural ✔

(water breaking) weakening of the
membranes of rom the
force of contractions.
Cramps and back pain Caused by contractions of

the muscles of the uterus
and by pressure on the
cervix.
Vaginal discharge The mucus plug helps
prevent bacteria from
traveling into the uterus.
When the cervix begins to
soften, thin, and
open, the mucus is
expelled into the vagina
Vaginal bleeding Caused by the rupture of
small blood vessels in the
cervix.
Bulging Perineum The protrusion in the ✔

perineal area during the
second stage of labor. It is
the characteristic sign of
impending birth and is
caused by
increased pressure in
the region.
CONCEPT MAP
RISK FACTORS
Predisposing Factor: Bulging perineum.
Protrusion in the perineal area during the
second stage of labor. It is
the characteristic sign of impending birth and is
caused by increased pressure in the region
Precipitating Factors: Strong contractions
lasting 45 seconds. The periodic tightening
and relaxing of the uterine muscle. LABORATORY/DIAGNOSTIC
TEST
Complete blood count (CBC)

PATHOPHYSIOLOGY test
A spontaneous vaginal delivery is Urinalysis

a vaginal delivery that happens 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.
CLINICAL MANIFESTATIONS
Strong contractions- These contractions
cause the upper part of the uterus to tighten
and thicken while the cervix and lower portion
of the uterus stretch and relax.
Fully dilated cervix- The cervix has
opened completely in preparation for childbirth.
MEDICAL DIAGNOSIS Rupture of amniotic sac- Caused by a
Active labor natural weakening of the membranes of rom
the force of contractions.
Bulging Perineum- The protrusion in the
perineal area during the second stage of labor.
MEDICAL SURGICAL NURSING MANAGEMENT

MANAGEMENT - Promoting comfort
Episiotomy - is an incision made - Provide emotional support and encourage
in the perineum. The tissue verbalization of feelings to reduce anxiety.
between the vaginal opening and - Check maternal vital signs.
the anus — during childbirth. - Establish a therapeutic relationship with the
pregnant woman and with her significant others.
MEDICAL MANAGEMENT
LABORATO INDICATIONS REFERENCE ACTUAL SIGNIFICANCE NURSING
RY/ VALUE FINDINGS OF THE CONSIDERATIONS
DIAGNOSTI FINDINGS
C TEST
Complete To identify and Hemoglobin: n/a Measures the Pre-procedure:
blood prevent 11.5-13.0 (13.5) numbers of - educate the patient
count problems, g/dl different types about the importance
(CBC) a CBC may of cells that of the test.
- is a set of be done before Platelets: make up your - Explain that slight
medical pregnancy, if 150,000 to blood to check discomfort may be felt
laboratory possible, at the 450,000 platelets for anemia, when the skin is
tests that beginning per microliter of infection and punctured.
provide of pregnancy, blood your blood- - Encourage to avoid
information and one or clotting ability. stress if possible.
about the more White blood cell:
cells in a times during 9,000-15,000 During/Intra-
person's pregnancy. cells per microliter procedure:
blood. The first - Apply manual
baseline pressure and
results can be dressings over
compared to puncture site.
later values to - Tell the patient to
look for relax.
changes that
could indicate Post-procedure:
a health issue. - Monitor the puncture
site for oozing or
hematoma formation.
- Instruct to resume
normal activities and
diet.
LABORATO INDICATIONS REFERENCE ACTUAL SIGNIFICANCE NURSING

RY/ VALUE FINDINGS OF THE CONSIDERATIONS
DIAGNOSTI FINDINGS
C TEST
Urinalysis A urine test is  Volume: 600 n/a Can detect Pre-procedure:
- is a used to assess to 2500 mL in some common - Instruct the patient to
simple test t bladder or 24 hours diseases. It may void directly into a
hat looks at kidney  Color: Pale be used to clean, dry container.
a small infections, yellow to screen for - Sterile, disposable
sample of diabetes, amber and/or help containers are
your urine. It dehydration,  Appearance: diagnose recommended
can help and clear to conditions such
find Preeclampsia slightly hazy as a urinary During/Intra-
problems by screening  Specific tract infections, procedure:
that need for high levels gravity: 1.005 kidney - Collect the specimen
treatment, of sugars, to 1.025 with disorders, liver and transfer to an
including proteins, a normal fluid problems, appropriate specimen
infections or ketones, and intake diabetes or container.
kidney bacteria. High  pH: 4.5 to 8 other metabolic - Cover all specimens
problems. levels of  Glucose: conditions tightly, label properly
sugars may negative and send immediately
suggest  Ketones: to the laboratory.
Gestational negative
Diabetes,  Blood: Post-procedure:
which may negative - Observe standard
develop  Protein: precautions when
around the negative handling urine
20th week  Bilirubin: specimens.
of pregnancy. negative - If the specimen
 Nitrate for cannot be delivered to
bacteria: the laboratory or
negative tested within an hour,
 Casts: it should be
negative, refrigerated or have an
occasional appropriate
hyaline casts preservative added.
 Red blood
cells:
negative or
rare
 Crystals:
negative or
none.
DRUG STUDY
DRUG MODE OF INDICATI CONTRAIN- SIDE EFFECTS/ NURSING
NAME ACTION ONS DICATIONS ADVERSE INTERVENTIONS
EFFECTS
Generic Name: Agonist of kappa - Analgesia Hypersensitivity to CNS - Question medical history
opioid receptors nalbuphine. Severe Effects: Nervousness, in Precautions
nalbuphine and partial respiratory depression,
antagonist of mu depression, acute restlessness, crying, - Obtain vital signs before
Brand Name: medication.
opioid receptors or severe bronchial euphoria, floating,
Nubain within CNS, asthma, GI hostility, unusual - Monitor for change in res
inhibiting obstruction dreams, confusion, B/P, rate/quality of pulse.
Therapeutic
ascending pain including paralytic faintness,
Class: - Monitor daily pattern of b
pathways. ileus. Cautions: hallucinations,
Opioid partial Therapeutic Hepatic/renal dysphoria, feeling of activity, stool consistency.
agonist. Effect: Alters impairment, heaviness, numbness,
- Initiate deep breathing, c
pain perception, respiratory tingling, unreality. The
Pharmacologic emotional exercises, particularly in p
depression, recent incidence of
class: pulmonary impairment
response to MI, recent biliary psychotomimetic
pain. tract impairment, effects, such as - Assess for clinical impro
Opioid
pancreatitis, unreality, record onset of relief of pa
analgesic.
hypovolemia, head depersonalization,
Actual Dose, trauma, increased delusions, dysphoria - Consult physician if pain
Timing and intracranial and hallucinations has not adequate.
Route: pressure (ICP), been shown to be less
pregnancy, pts than that which occurs
For IV push, suspected of being with pentazocine.
administer opioid dependent,
each 10 mg obesity, thyroid Cardiovascular: Hyper
over 3–5 min. dysfunction, tension, hypotension,
prostatic bradycardia,
hyperplasia, tachycardia.
urinary stricture,
adrenal Gastrointestinal: Cra
insufficiency, mps, dyspepsia, bitter
cardiovascular taste.
disease, elderly
pts, debilitated pts. Respiratory: Depressi
on, dyspnea, asthma.
Dermatologic: Itching,
burning, urticaria.
Miscellaneous: Speec
h difficulty, urinary
urgency, blurred vision,

flushing and warmth.
Allergic
Reactions: Anaphylacti
c/anaphylactoid and
other serious
hypersensitivity
reactions have been
reported following the
use of nalbuphine and
may require immediate,
supportive medical
treatment. These
reactions may include
shock, respiratory
distress, respiratory
arrest, bradycardia,
cardiac arrest,
hypotension, or
laryngeal edema. Some
of these allergic
reactions may be life-
threatening. Other
allergic-type reactions
reported include stridor,
bronchospasm,
wheezing, edema, rash,
pruritus, nausea,
vomiting, diaphoresis,
weakness, and
shakiness.
DRUG MODE OF INDICATIONS CONTRAIN- SIDE EFFECTS/ NURSING

NAME ACTION DICATIONS ADVERSE INTERVENTIO
EFFECTS
Generic Name: Activates - Induction or Hypersensitivity SIDE EFFECTS - Assess baselines for
receptors that Stimulation of to oxytocin. Occasional: Tachycardia, signs, B/P, fetal heart
oxytocin trigger Labor Adequate premature ventricular
increase in uterine activity contractions, hypotension, - Determine frequency
Brand Name: - Control of duration, strength of
intracellular that fails to nausea, vomiting. Rare:
Pitocin calcium Postpartum progress, Nasal: Lacrimation/tearing, contractions.
levels in Bleeding cephalopelvic nasal irritation, rhinorrhea,
Therapeutic - Monitor B/P, pulse,
uterine disproportion, unexpected uterine respirations, fetal hear
Class:
myofibrils; fetal distress bleeding/ contractions. intrauterine pressure,
Uterine increases without ADVERSE contractions (duration
smooth prostaglandin imminent EFFECTS/TOXIC frequency) q15min
muscle production. delivery, grand REACTIONS Hypertonicity
stimulant. Therapeutic multiparity, may occur with tearing of - Notify physician of
Effect: hyperactive or uterus, increased bleeding, contractions that last l
Pharmacologic Stimulates hypertonic abruptio placentae (i.e., than 1 min, occur mor
Class: uterine uterus, obstetric placental abruption), frequently than every
contractions. emergencies cervical/vaginal lacerations. stop
Oxytocic
that favor Fetal: Bradycardia,
agent. - Maintain careful I&O
surgical CNS/brain damage, trauma
to potential water intox
Actual Dose, intervention, due to rapid propulsion, low
Timing and prematurity, Apgar score at 5 min, - Check for blood loss
Route: unengaged fetal retinal hemorrhage occur
head, rarely. Prolonged IV
Injection unfavorable fetal infusion of oxytocin with
(Pitocin): position/ excessive fluid volume has
10 units/mL. presentation, caused severe water
when vaginal intoxication with seizures,
delivery is coma, death.
contraindicated
(e.g., active
genital herpes
infection,
invasive cervical
cancer, placenta
previa, cord
presentation).
Cautions:
Induction of
labor should be
for medical, not
elective,
reasons.
Generally not
recommended
in fetal distress,
hydramnios,
partial placental
previa,
predisposition to
uterine rupture
NURSING CARE PLANS

CUES/DATA NURSING NSG GOAL NURSING RATIONALE EVALUATION

DIAGNOSIS AND INTERVENTIONS
OBJECTIVES
SUBJECTIVE Pain related to labor After 30 1. Perform a 1. Assessment After 30 minutes of
DATA: contractions as minutes of comprehensive is the first step intervention:
patient may evidenced by having nursing assessment. Assess in managing The patient’s pain
have a strong contraction intervention: location, pain. It helps was relieved and
verbalized: lasting 45 seconds The patient’s characteristics, ensure that controlled.
“ang sakita pain will be onset, duration, the patient
naman kaajo SCIENTIFIC DATA: relieved or frequency, quality receives
controlled,
mura naman Unpleasant and severity of pain. effective pain
patient will be
kog sensation and able to make relief.
makujapans ka emotional an informed
sakit” experience that links decision
to tissue damage. It regarding pain 2. Accept the 2. Pain is
OBJECTIVE allows the body to control options patient’s description highly
DATA: react and prevent she would like of pain subjective.
to use, and will
- Facial further tissue
express relief
Grimace damage. People feel obtained from 3. Asses pain 3. Provides
- Uncomfortable pain when a signal labor pain by location intensity information to
- Irritability travels through nerve the use of child (scale of 0-10) aid in
- Restlessness fibers to the brain for birth duration. determining
interpretation. techniques choice or
VITAL SIGNS: learned and/or effectiveness
comfort
BP: 130/80 SOURCE: of intervention.
measures /
medicalnewstoday analgesics
PAIN SCALE: .com given.
9/10 4. Provide comfort 4. Promotes
measure like back relaxation,
rub, helping position refocuses
of comfort. Suggest attention, and
use of relaxation may enhance
technique and deep coping abilities
breathing exercises
5. Obtain vital sIgns 5. Vital signs

are usually
affected when
pain is present
6. Anticipate the 6. Early and

need for pain timely
management. intervention is
the key to
effective pain
management.
It can even
reduce the
total amount
of analgesia
required.
7. Encourage 7. This helps

patient to use the patient
breathing achieve
techniques and generalized
positive affirmations. relaxation
which aids in
reduced
perception of
pain.
8. Assess if patient 8. Provide

attended childbirth necessary
classes; if yes, information so
determine the the nurse can
childbirth techniques reinforce
taught. pyschopylac-
tic methods of
coping or
initiate
teaching of
non-
pharmacologic
comfort
measures that
can be used
during stages
of labor.
9. Teach patient
pain control options
9. Providing
available, giving the
information
pros and cons of
allows the
each
patient to
make
informed
decision
regarding pain
control
10. Provide teaching
between uterine
contractions. 10. The
patient is more
attentive and
can better
internalize
information
when not in
pain.
CUES/DATA NURSING NSG GOAL NURSING RATIONALE EVALUATION

DIAGNOSIS AND INTERVENTIONS
OBJECTIVES
SUBJECTIVE Anxiety After 30 minutes 1. Explain the 1. Information After 30 minutes of
DATA: related to of nursing procedures, nursing and knowledge nursing intervention:
N/A situational intervention, the interventions, and of the reasons of
patient will be The patient appeared
OBJECTIVE crisis and treatment regimen. these activities
able to: relaxed with vital
DATA: perceived or Keep can decrease
Appear relaxed; signs within normal
- Facial actual threats with maternal vital communication fear of the limits and anxiety is
grimace to self and signs within open; discuss with unknown. reduced/manageable.
- fetus normal limits and the client the
Uncomfortable evidenced by anxiety is reduced possible side
- Heavy increasing and/or effects and
manageable.
breathing tension. outcomes while
- maintaining an
Restlessness Scientific optimistic attitude.
Basis:
Vague 2. Orient client and 2. Helps client
uneasy partner to labor and/or significant
feeling of suite environment. others feel at
discomfort or ease and more
dread comfortable in
accompanied their
by an surroundings.
autonomic
response (the 3. Can help
source is 3. Encourage reduce anxiety
often verbalization of and stimulate
nonspecific or fears or concerns. identification of
unknown to coping
the behaviors.
individual); a
feeling of 4. Monitor maternal 4. Vital signs of
apprehension and fetal vital signs. client and fetus
caused by may be altered
anticipation of by anxiety.
danger. It is Stabilization may
an alerting reflect reduction
sign that anxiety level.
warns of
impending
danger and 5. Answer 5. Provision of

enables the questions honestly, clear information
individual to especially can help the
take information client or couple
measures to regarding understand what
deal with that contraction pattern is happening and
threat. and fetal status. may reduce
anxiety.
6. Encourage use of
Source: relaxation 6. Enables the
Doenges, M. techniques. client to obtain
E., maximum benefit
Moorhouse, from rest
M. F., & Murr, periods; prevents
A. C. (2008). muscle fatigue
Nurse's and improves
pocket guide: uterine blood
Diagnoses, flow.
prioritized 7. Assess support
interventions, systems available 7. The
and to the client or assistance and
rationales. couple. caring of
Philadelphia, significant
Pensylvennia: others, including
F.A. Davis caregivers, are
Company. extremely
important during
this time of
uncertainty and
8. Provide massage stress.
and backrubs for
patient to reduce 8. This aids in
anxiety. reduction in
anxiety.
9. Interact with
patient in a peaceful 9. The nurse or
manner. health care
provider can
transmit his or
her own anxiety

to the
hypersensitive
patient. The
patient’s feeling
of stability
increases in a
calm and
nonthreatening
environment.
10. Administer
sedative if other 10. Provides
measures are not soothing and
successful.
tranquilizing
effect.
CUES/DATA NURSING NSG GOAL AND NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTIONS
SUBJECTIVE Acute pain After 30 minutes of 1. Assess current 1. Allows the nurse After 30
DATA: related to nursing intervention, knowledge of to develop an minutes of
effects of the patient will be able obstetric pain individualized nursing
N/A labor and to: intervention,
control measures. teaching plan for
delivery the client was
Express relief the patient.
process able to:
obtained from labor
OBJECTIVE pain by the use of Appear relieved
DATA: childbirth techniques obtained from
2. Provides
learned and/or comfort 2. Assess if patient labor pain.
- Facial necessary
measures, attended childbirth
grimace information so
analgesics/anesthetics classes; if yes,
- nurse can
give. determine the
Uncomfortable reinforce
- Heavy
childbirth
psychoprophylactic
breathing techniques taught.
methods of coping
- Restlessness or initiate teaching
Pain scale: of
nonpharmacologic
9/10
comfort measures
that can be used
during stages of
labor.
3. Provide positive
reinforcement and 3. Positive
encouragement to reinforcement and
patient and support encouragement
persons as they provide the patient
apply and support
nonpharmacolgic person a sense of
techniques learned control and self-
in childbirth confidence.
classes. Assist with
techniques as
necessary.
4. Assess anxiety
level and
4. Allows for
implement
clearly intervention
measures to
to decrease
reduce anxiety as
anxiety levels.
needed.
High levels of
anxiety can
increase the
perception of pain,
and decrease
comprehension of
verbal instruction.
5. Provide teaching 5. The patient is

between uterine more attentive and
contractions. can better
internalize
information when
not in pain.
6. Teach patient 6. Providing

pain control options information allows
available, giving the patient to make
pros and cons of informed decisions
each. regarding pain
control.
7. Initiate 7. These
teaching/reinforcing nonpharmacologic
of comfort measures
nonpharmacologic work by providing
comfort measures diversion during
that can be used uterine
during labor if contractions.
needed. Assist with
implementation of
these measures as
needed.
HEALTH TEACHING PLAN
Learning Content Learning Time Learning Processing

Outcome Methodology Allotment Material Question
1. Welcome talk 40 minutes • 1 laptop 1. Why do
After 40 minutes & introduction composed of: you think that
of the host. • 1 speaker learning
of client/family
Host will begin • 5 minutes’ patterned
teaching, they will
welcome talk •1
be able to: with a warm microphone breathing
welcome and a and during labor
1. Know the - Definition of small introduction. and delivery
meaning and patterned introduction is important?
• 25 minutes for
benefits of breathing and its about the topic the discussion 2. Can you
patterned benefits. and its content. and demonstrate
breathing during
2. Discussion demonstration on how
labor and
about the topic of the topic and would you
delivery.
- Steps on how with regards to its contents. help the
2. Know and to help the its content. patient during
patient begin the • 5 minutes of
demonstrate on these times?
patterned 3. Video video
how to begin
breathing. presentation to presentation
patterned 3. Can you
breathing. present to the • 5 minutes for demonstrate
audience for questions and the 3
3. Know and better
- 3 different conclusion. techniques
demonstrate 3 understanding.
patterned on
techniques on
breathing patterned
patterned 4. Return
techniques for breathing
breathing for the demonstration.
the first stage of
first stage of during the
labor.
labor. first stage of
labor?
4. Know and
demonstrate the - Proper
proper breathing
technique for the techniques for
second stage of the second stage
labor. of labor.
DISCHARGE INSTRUCTION PLAN
S Subjective cues
• “I don’t feel any pain anymore.”
• “I want to go home.”
O Objective cues
• Normal vital signs

• Recovering from delivery and are beginning to care for the newborn.
M Medications
• Ibuprofen 600 mg every 6 hours as needed for pain.
• Continue your prenatal vitamins as long as you are breast feeding or for 30days after
delivery.
• For cracked/sore nipples you may use Lanolin cream.

E Environmental Modifications
• Surround yourself with family/friends.

• Give and show all kinds of support to the patient, encourage them to talk about their
feelings and listen without judgment.
• Seek help. Don’t hesitate to accept help from family and friends during the postpartum
period, as well as after this period. Your body needs to heal, and practical help around
the home can help you get much-needed rest. Friends or family can prepare meals, run
errands, or help care for other children in the home.
T Treatment (non-pharmacologic treatment)
• Physical and emotional support

• Good diet
H Health teachings
• Balance activities with adequate rest periods and stay hydrated all day long.
• Eat healthy meals. Maintain a healthy diet to promote healing. Increase your intake of
whole grains, vegetables, fruits, and protein.
• Exercise. Your doctor will let you know when it’s okay to exercise. The activity should
not be strenuous.
O Observable signs/ symptoms (cues for seeking prompt management)
• Very heavy, foul-smelling bleeding

• A red or swollen leg that feels warm or painful when you touch it
• A bad headache that doesn’t get better after taking medication, or a bad headache that
affects your vision
• A fever of 100.4 F or higher
• An incision that isn’t healing

D Diet modifications
• At every meal, fill half your plate with fruits and vegetables. The other half should
include whole grains like brown rice, whole-grain bread, or oatmeal.
• Foods like beans, seafood, lean meats, eggs, and soy products are rich in protein, which
help your body recover from childbirth. Aim for five servings each day, or seven if
you’re breastfeeding.
JOURNAL READING 1
An audit of external cephalic version procedures at Kings College Hospital

Rehal A , Datta S
Kings College Hospital, London, UK
Objectives
External cephalic version (ECV) is a method commonly used to manipulate the fetus
abdominally to a cephalic presentation. The purpose of this audit was to evaluate all ECV
procedures over a one‐year period in our unit, to analyse subsequent pregnancy
outcomes and compare these with previous audits.
Design
This was a retrospective audit, analysing all ECV procedures performed in the year 2017.
Methods
Data queries were used to extract all patients with a non‐cephalic fetus at the routine
36 weeks’ scan, and a second query extracted all breech deliveries.
Results
250 fetuses were breech at the routine 36 weeks’ scan. From these, 110 ECV procedures
were attempted. 34.6% were successful and 86% of these patients had a vaginal delivery.
From those procedures that failed, all patients delivered by caesarean section. A greater
success rate was seen in multiparous compared with nulliparous patients (51% versus
26%). When compared with the results from previous audits, there had been an overall
increase in ECV procedures; however, the success rate had fallen compared to the
previous year.
Conclusion
The results show that antenatal detection of breech presentation is extremely high in our
unit and can be explained by the routine 36 weeks’ scan. ECV remains one of the principal
methods to reduce the incidence of breech presentation, thereby potentially avoiding
caesarean section and its sequelae. Further audit would need to be carried out looking at
the factors associated with failure in terms of case selection and operator experience.
JOURNAL READING 2
Mode of Vaginal Delivery: A Modifiable Intrapartum Risk Factor for Obstetric Anal
Sphincter Injury
By: Marta Simó González
Obstetric anal sphincter injury encompasses third and fourth degree

perineal tearing that occurs during delivery, according to Sultan’s classification. This
classification considers perineal injuries as a 3rd degree tear when there is any
involvement of the anal sphincter and 4th degree tear when the anal epithelium is
involved. This classification is incorporated in the RCOG guidelines and included in the
Green Top Guidelines for the Management of Third and Fourth-Degree Perineal Tears
Following Vaginal Delivery. Third degree tears are further classified into three subgroups
according to the extent of damage to the external anal sphincter and internal anal
sphincter. The incidence of obstetric anal sphincter injury varies between 0.5 and 5% of
vaginal deliveries and it is the most common cause of anal incontinence in healthy women
[3]. Obstetric anal sphincter injury is a serious complication of childbirth due to its notable
maternal morbidity, its serious physical and emotional effects, and its impact on quality of
life. Awareness of the factors most frequently associated with this injury is essential and
can help obstetricians perform safer deliveries for both mother and child. A total of 4526
vaginal births were recorded during the study period. Obstetric anal sphincter injury
occurred in 97 cases, giving an incidence of 2.14% (CI 95% = 1.72–2.57).
Source: https://www.hindawi.com/journals/ogi/2015/679470/
REFERENCES
https://nyepartners.com/nsvdserv/
https://www.healthline.com/health/pregnancy/spontaneous-vaginal-delivery#Should-
you-have-a-spontaneous-vaginal-delivery?
https://courses.lumenlearning.com/boundless-ap/chapter/birth-parturition/
EVALUATION AND IMPLICATION TO:
1. Nursing Practice
Knowledge, skills and attitude should always be present on the practice of the
nursing profession. In carrying out the nursing actions & interventions, the
underlying principles and standards must always be observed to provide total
patient care. The nursing care plans in this presentation will aid the learners in
the care of the patients.
2. Nursing Education
This presentation will help future students gain knowledge about the case – Beta
thalassemia major and provide them insight on how to care and manage patients
with this disease. This case presentation will also encourage health teaching to
caregivers and other health care professionals.
3. Nursing Research
In the field of research, this case presentation will encourage effective therapeutic
management for patients undergoing normal spontaneous vaginal delivery. It will
also give more insights to future researchers about the normal spontaneous
vaginal delivery and its nursing management.

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THE COLLEGE OF MAASIN

“Nisi Dominus Frustra”

A CASE STUDY ON NORMAL SPONTANEOUS VAGINAL DELIVERY

In Partial Fulfillment of the Requirements in NCM- 104 RLE

 Place baby in skin-to-skin contact on the mother's abdomen; encourage

I. NURSING HEALTH HISTORY

GORDON’S FUNCTIONAL HEALTH PATTERN

A. Health Perception and Health Maintenance Management Pattern

B. Nutritional & Metabolic Pattern

She can void 3 to 4x a day without any pain felt

She can defecate once a day with a formed stool

G. Self-Perception and Self-Concept Pattern

H. Role relationship pattern

Patient experienced sexual intercourse

J. Coping stress pattern

A. ERICKSON’S PSYCHOSOCIAL DEVELOPMENT TASK

HAVINGHURST’S DEVELOPMENTAL TASK

PREDISPOSING RATIONALE ACTUAL JUSTIFICATION

PRECIPITATING RATIONALE ACTUAL JUSTIFICATON

ANATOMY AND PHYSIOLOGY

Rupture of amniotic sac Caused by a natural ✔

Cramps and back pain Caused by contractions of

Bulging Perineum The protrusion in the ✔

Complete blood count (CBC)

A spontaneous vaginal delivery is Urinalysis

MEDICAL SURGICAL NURSING MANAGEMENT

LABORATO INDICATIONS REFERENCE ACTUAL SIGNIFICANCE NURSING

urgency, blurred vision,

DRUG MODE OF INDICATIONS CONTRAIN- SIDE EFFECTS/ NURSING

NURSING CARE PLANS

CUES/DATA NURSING NSG GOAL NURSING RATIONALE EVALUATION

5. Obtain vital sIgns 5. Vital signs

6. Anticipate the 6. Early and

7. Encourage 7. This helps

8. Assess if patient 8. Provide

CUES/DATA NURSING NSG GOAL NURSING RATIONALE EVALUATION

danger and 5. Answer 5. Provision of

her own anxiety

CUES/DATA NURSING NSG GOAL AND NURSING RATIONALE EVALUATION

5. Provide teaching 5. The patient is

6. Teach patient 6. Providing

HEALTH TEACHING PLAN

Learning Content Learning Time Learning Processing

DISCHARGE INSTRUCTION PLAN

• Normal vital signs

• Ibuprofen 600 mg every 6 hours as needed for pain.

• For cracked/sore nipples you may use Lanolin cream.

• Surround yourself with family/friends.

• Physical and emotional support

• Very heavy, foul-smelling bleeding

• A fever of 100.4 F or higher

• An incision that isn’t healing

An audit of external cephalic version procedures at Kings College Hospital

By: Marta Simó González

Obstetric anal sphincter injury encompasses third and fourth degree

EVALUATION AND IMPLICATION TO:

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