NORMAL SPONTANEOUS VAGINAL DELIVERY

NSVD

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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 mother’s 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 mother’s 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 mother’s 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 mother’s 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 mother’s 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

client’s history, health status, functional status and coping pattern. These vital

informations provide a conceptual baseline data utilized in developing nursing diagnosis, subsequent
plans for individualized care and for the nursing process application as a whole. In keeping the private
life of my patient and in maintaining confidentiality, let me hide for with the pseudonym of Patient P.
Patient P was born on December 19, 1992. She was born to parents from Surigao Del Norte

, but she didn’t

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

doesn’t 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 P’s watcher, i

t 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 she’d make any noise, she’d get killed.

Ill-fatedly, she was held powerless to the man, and the crime had happened. Fortunate enough that she

wasn’

t 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 couldn’t 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 siya’y sala

.‖

According to Erik Erikson’s 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,

doctor’s 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: 32 cm

Chest Circ: 30 cm

Abd Circ: 20 cm Extemporaneously, the baby cried with the same breathing time of 3:36am.

Patient P’s 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. Pos

t partum doctor’

s 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 P’s temperature was monitored until stable.

On the following day, June 30, 2008,

doctor’s order was to secure

HBsAg result.

Patient P’s 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 patient’s

condition. Upon assessing, I was able to take and record her vital signs:

T = 37.3°c

82 bpm

21 cpm

120/70 mmHg Patient P wasn

’t 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, doctor’s 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, doctor’

s 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 mother’

s 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 patient’s 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 5’4, 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.