Introduction:

Pregnancy is 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: caesarean section and 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. A vaginal delivery is the
recommended method of childbirth for women whose babies have reached full term. However,
vaginal deliveries are not recommended for women who have had cesarean deliveries before, or
who have infections that can be transferred to their baby through vaginal delivery.

A postpartum period or postnatal period is the period beginning immediately after the birth of a
child and extending for about six weeks. Less frequently used are the terms puerperium or
puerperal period. The World Health Organization (WHO) describes the postnatal period as the
most critical and yet the most neglected phase in the lives of mothers and babies; most deaths
occur during the postnatal period. It is the time after birth, a time in which the mother's body,
including hormone levels and uterus size, returns to a non-pregnant state.

Objectives

Main Goal

❏ Through the utilization of the nursing process, the main goal of this case study is to
understand the complexity of a Normal Spontaneous Delivery in the most inclusive way
possible. The learnings that will be obtained from this study will serve as a guide and will
develop the skills and understanding of the students focusing on the same topic.

Specific Objectives

❏ Examine the patient’s condition through careful assessment.

❏ Interact with the patient to build rapport and trust; gather significant data.
❏ Understand the different procedures done, and its rationale.
❏ Utilize the different techniques to assess the patient.
❏ Identify the pre-existing health problem the patient has.
❏ To formulate a postpartum discharge plan for the continuity of care.
I. Patient's Identification
Name: S.B
Age: 23
Ethnicity: Filipino
Gender: F

II. Medical History

A. Chief Complaint:

Patient complains of experiencing unrelieved labor pain for 3 hours

B. History of Present Illness

Prior to admission, Patient S.B had painful contractions for 3 hours and leakage of fluid for 2
hours. She was admitted with a chief complaint of labor pain with watery vaginal discharge. Her
labor lasted for 25 minutes and at 2:14 pm she gave birth to a live, baby boy via NSD.

C. Past Medical History

Patient S.B has no known food or drug allergies. She has complete immunizations, had no
injuries or surgeries, and reported that she has no previous hospitalizations.

Social History:
Patient S.B grew up in Manila with her parents, and she has 1 older sibling. She is a college
graduate and denies having a job, and is currently financed by her parents and live-in partner.
Patient S.B reports that she drinks a limited amount of alcohol occasionally, denies use of
tobacco and any recreational drugs/abused substances.

OB-Gyne History:
Patient S.B's age at menarche is 12 years old. She stated that she has regular menstruation, and
also experiences dysmenorrhea. She became sexually active at 21 years of age, (with a single
male partner) with no use of any contraceptives. She has no history of any sexually transmitted
disease. Her obstetric score is G1P0, and her last menstrual period was on May 26, 2020. During
the course of her pregnancy, she completed her pre-natal check-ups and she is regularly taking
her ferrous sulfate supplement. She has no history of bleeding, and any discomfort during her
pregnancy until her labor and delivery.

D. Family Medical History

Genogram

Patient S.B has one older sibling with no current illness. Patient S.B's father has hypertension
and is currently taking his maintenance. Her mother also has hypertension, and asthma and is
taking maintenance and medications to control her asthma. Patient S.B's grandfather died from a
heart disease at age 65, while her grandmother is still living and has diabetes and hypertension.

E. Review of Systems

Date Performed: February 24, 2020

System

Constitutional Denies fatigue, changes in appetite, malaise, fever, unexplainable weight loss.
symptoms

Denies change in vision, eye pain, redness, discharge.

Eyes

Ears, nose, mouth, Denies frequent nose bleeds, sinus pain, stuffy ears, ear pain, ringing in ears, gingival bleeding,
and throat (ENT) toothache, oral sores, pain with swallowing

Denies chest pain, shortness of breath, exercise intolerance, edema, palpitations, faintness, loss of
Cardiovascular consciousness, claudication

Respiratory Denies cough, sputum, hemoptysis, shortness of breath, exercise intolerance, breathing difficulties

Gastrointestinal Denies heartburn, swallowing difficulty, abdominal pain, diarrhea, constipation

Urinary Denies incontinence, pain when urinating, ,hematuria, nocturia, polyuria, hesitancy, terminal dribbling,
decreased force of stream

Denies muscle pain, stiffness, joint swelling, decreased range of motion.

Musculoskeletal

Integumentary Denies itchiness, pertinent rash, lesions, loss of hair.

Neurological Denies any changes in sight, smell, hearing and taste, seizures, faints, headache, pins and needles
(paraesthesiae) or numbness, limb weakness, difficulty maintaining balance, difficulty with speech
production.
Denies depression, changes in sleep patterns, anxiety, difficult concentrating, negative body image,
Psychiatric paranoia, lack of energy, episodes of mania, episodic change in personality, sexual or financial 'binges',

Hyperthyroid: Denies preference of cold weather, mood swings, sweaty, diarrhoea, oligomenorrhoea,
Endocrine weight loss despite increased appetite, tremor, palpitations, visual disturbances;
Hypothyroid - Denies preference hot weather, slow, tired, depressed, thin hair, croaky voice, heavy
periods, constipation, dry skin
Diabetes: denies excessive thirst, urine production and constant hunger, also denies symptoms of
hypoglycemia such as dizziness, sweating, headache, hunger, tongue disarticulation
Adrenal: denies experiencing hyper/hypotension.
Reproductive (female): menarche at 12 years old, length of cycle is 28 days, denies any irregular
bleeding, denies use of birth control pills or any contraceptives

Hematologic/ Denies unusual, prolonged or excessive bleeding, use of anticoagulant and antiplatelet drugs (including
lymphatic aspirin), no family history of hemophilia, history of a blood transfusion. She also denies being easily
bruised.

Allergic/ Denies experiencing breathing difficulties or "choking" (anaphylaxis) as a result of exposure to any
immunologic allergens, swelling or pain at groin(s), axilla(e) or neck (swollen lymph nodes/glands), allergic response
(rash/itch) to materials, foods, animals (e.g. cats); reaction to bee sting, unusual sneezing (in response
to what), runny nose or itchy/teary eyes; food, medication or environmental allergy test(s) results.

F. Physical Assessment (PA):

Date Performed: February 24, 2020

Parameters Method Normal findings Patient findings Implication

used

General Cooperative and well-

Appearance No distress, relaxed, oriented, properly
correct posture, well- groomed,
 Inspection groomed, able to
follow instructions,
speech is logical and
consistent

Symmetrical and in
Head, Scalp, Inspection, Rounded, normal contour Hair color comes from
Skin & Nails Palpation normocephalic and Hair is evenly melanin production and
symmetrical, smooth, distributed may vary from pale blonde
no lesions and has Good skin turgor is to total black The patient
uniform consistency. noted has normal nails. No
Absence of nodules Intact skin, warm and deviations were present. In
or masses. Hair moist skin, hair is younger persons, skin
should be evenly evenly distributed, should be smooth and not
distributed, thick, and nails are convex in wrinkly.
silky. shape, presence of
grooves (Kozier & Erb’s 8th
Should be uniform in edition, page 585)
color, unblemished
and no presence of any
foul odor, temperature
is within normal limit.

Eyes are symmetrical,

Eyes Inspection, Eyebrows: evenly brown in color No deviations were noted.
Palpation distributed hair, With pinkish
should be conjunctiva
symmetrically No edema of the
aligned. Eyelashes eyelids
must be equally
distributed and curled
slightly outward.
Sclera appears white,
PERRLA. Movement
of both eyes are
coordinated. No
discharges, lesions,
swelling, or pain,

Symmetrical, properly
Ears Inspection, Symmetrical, aligned aligned Normal Findings.
Palpation with the outer Ears are clean, voice is
canthus of eye, audible to both ears.
uniform in color, no
redness, swelling,
lesions, firm and
 discharge. Client can
hear clearly with both
ears.

Symmetric in shape,
Nose Inspection, Symmetric, straight uniform in color, no The nose may appear more
Palpation and uniform in color. tenderness, lesions, prominent on the face
No presence of redness, and discharge, from a loss of
discharge or flaring. mucosa is pink, and subcutaneous fat.
No tenderness and moist. (Physical Examination &
lesions. Health Assessment, Fifth
edition. Jarvis pp. 393)

Mucosa moist, pink

Mouth Inspection without lesion. Gums Oral mucosa and Normal findings, no
pink without gingival are pink in deviations were noted.
bleeding, tongue is color, moist and there
centrally positioned, were no lesions nor
uvula of the client is inflammation noted
positioned in the
midline. No cracked corners in
the mouth is seen

Head centered,
Neck Inspection, The neck muscles are coordinated smooth Patient show no
Palpation equal in size. Soft movements, absence of abnormalities.Head size
and supple with full visible lumps, no and shape vary, especially
range of motion. palpable lymph nodes. in accord with ethnicity.
Lymph nodes are not Usually the head is
palpable, trachea is symmetric, round and
placed in the midline, erect and in midline. In
thyroid glands ascend older clients, facial
during swallowing wrinkles are prominent
but are not visible. because subcutaneous fat
decreases with age.
(Kozier & Erb’s
fundamentals of nursing)

No presence of
CV Inspection, There should be no abnormal pulsations, No deviations were noted.
Palpation, visible pulsations on lifts of heaves, jugular
Auscultation the aortic and veins not visible,
pulmonic areas. No symmetric peripheral
jugular distention. pulsations
There is no presence
 of heaves or lifts.

Symmetric thorax,
Resp Inspection, The chest wall is effortless and clear Normal; Findings shows
Palpation, intact with no breath sounds, no abnormalities.
Auscultation tenderness and vertically aligned
masses. Clear to spine.
auscultation
bilaterally without
wheeze, rales or
rhonchi. The spine is
vertically aligned.

Presence of striae
Abdomen Inspection, The abdomen has a gravidarum and linea These skin pigment
Auscultation symmetric contour. nigra. changes are not totally
Should be smooth No distended bowel understood. It is thought
and uniform in color. from constipation. that high levels of
pregnancy hormones cause
the pigment-producing
cells in the skin
(melanocytes) to make
more pigment.

No edema noted;
Extremities Inspection, The extremities are Filling of nail bed is Normal; findings doesn’t
Palpation symmetrical in size under 3 seconds show any abnormal
and length. No varicosities seen at strength or swelling on
the lower extremities, joints.
Muscles: The extremities are
muscles are not symmetrical in size
palpable with the and length. Movements
absence of tremors. are well-coordinated,
They are normally no tremors and
firm and showed discomfort noted.
smooth, coordinated
movements.

Bones: There should

be no presence of
bone deformities,
tenderness and
swelling.

Joints: There should

 be no swelling,
tenderness and joints
move smoothly.

Rounded in shape,
Breast Inspection, Rounded shape, slightly unequal in At around 3–5 days after
Palpation, slightly size, skin is intact, no delivery, the milk comes
asymmetrical, no skin inversion of nipples, in. A good indicator of this
lesions, nipples are areolar area is is that the colostrum — the
everted. No signs of darkened, full and firm thick, yellow fluid
infections (swelling, as palpated. becomes lighter in color
redness, pain, With small amounts of and thinner in consistency.
warmth) breastmilk leaking. Full breasts are a regular
No palpable nodule or part of the postdelivery
lump, no signs of experience. the breasts
infection. remain enlarged until
breastfeeding is over.
They may then return to
their original size, become
smaller than before, or
remain slightly larger.

With well contracted

Uterus Inspection, Should not be uterus, aligned at the Immediately after delivery
Palpation, deviated to one side. midline and palpable of the placenta, the uterus
Must be firm and below the level of begins to return to its
contracted. umbilicus. nonpregnant size and
condition, a process
termed uterine involution.

Return of urination,
Bladder Inspection minimum of 150 mL No distended bladder Pregnancy causes reduced
Function per void, which should from retention muscle tone in the bladder
occur within 6 to 8 starting in the third month.
hours of delivery The bladder gradually
No bladder distention stretches, and grows, as
the pregnancy progresses.
The bladder continues to
lose muscle tone in the
early postpartum period.
There can be some
temporary nerve issues
after delivery, which
decrease your sensation
(the feeling that you need
 to urinate). Temporary
swelling after delivery can
also affect your urination.
If urine remains in the
bladder after urinating, it
can cause stretching of the
bladder. It can also cause
damage to the muscles of
the bladder. This can lead
to permanent bladder
injury.

Bowel sounds are

Bowel Inspection, Bowel movement noted. Patient has Normally, bowel
Function Auscultation after delivery may be defecated once, 2 days movements will resume
delayed to the third after delivery. within the first few days
or fourth day after following delivery.
delivery. There Constipation can occur
should be presence of after delivery.
bowel sounds.

Rubra (red) - lasts 3 Presence of lochia

Lochia Inspection to 5 days, should not rubra, minimal in Lochia is the vaginal
saturate one pad in amount, musty in odor, discharge after giving
less than an hour, no large blood clots. birth, containing blood,
foul-smelling, and no mucus, and uterine tissue.
large blood clots. Lochia discharge typically
continues for four to six
weeks after childbirth, a
time known as the
postpartum period or
puerperium.

Post episiorrhaphy
Episiotomy/ Inspection Redness is with suture lines noted, Episiotomy, also known as
Perineum considered normal no edema, discharge, perineotomy, is a surgical
with episiotomies and and no formation of incision of the perineum
lacerations; absence hemorrhoids. and the posterior vaginal
of discharge from the wall generally done by a
episiotomy or midwife or obstetrician.
laceration, no edema,
no ecchymosis, and
no formation of
hemorrhoids.
 No presence of pain
Homan’s Inspection, Presence of pain noted during The most obvious
Sign Palpation when eliciting the dorsiflexion of foot, or symptom of DVT is
Homan’s sign when ambulating. swelling and heavy pain or
indicates the probable extreme tenderness in one
presence of a DVT. of your legs. Up to 90
percent of DVT cases in
pregnancy occur in the left
leg.
III. Psychosocial History

A. Demographic Data:
Civil Status: Single
Educational Attainment: College Graduate
Occupational History: N/A
Religion: Roman Catholic
Place of birth: Paco, Manila

IV. Anatomy and Physiology

Reproductive System

➢ External Genitalia- our overview of the reproductive system begins at the external genital
area— or vulva—which runs from the pubic area downward to the rectum. Two folds of
fatty, fleshy tissue surround the entrance to the vagina and the urinary opening: the labia
majora, or outer folds, and the labia minora, or inner folds, located under the labia
majora. The clitoris, is a relatively short organ (less than one inch long), shielded by a
hood of flesh. When stimulated sexually, the clitoris can become erect like a man's penis.
The hymen, a thin membrane protecting the entrance of the vagina, stretches when you
insert a tampon or have intercourse.
➢ Vagina – the tubular structure that measures 3 – 4 inches long and lined with squamous
epithelium. The muscular and erectile tissues of the vaginal wall allows enough dilatation
and contraction to accommodate the passage of the fetus during labor, as well as
penetration of the penis during intercourse.
➢ Uterus – it is a pear-shaped, hollow, muscular organ located between the bladder and the
rectum. The uterine walls consist of an outer serosal layer, the perimetrium; a middle
muscular layer, the myometrium; and an inner mucosal layer, the endometrium. The
uterus consists of the fundus, body (or the corpus), and cervix. The body makes up 80%
of the uterus connects with the cervix at the isthmus, or neck. The cervix is the lower
portion of the uterus that projects into the anterior wall of the vaginal canal.

V. Pathophysiology
VI. Medical-Surgical Management

A. Laboratory and Diagnostic Examination

Clinical Microscopy - Urinalysis

PHYSICAL EXAMINATION MICROSCOPIC FINDINGS

Color: Light yellow Cast:

Transparency: Turbid Hyaline: /LPF
pH: 6.5 Fine Granular: /LPF
Specific Gravity: 1.105 Coarse Granular: /LPF
Waxy: /LPF
RBC: /LPF
WBC: /LPF

CHEMICAL EXAMINATIONS Cells:

WBC: 6-8 /HPF
Protein: NEGATIVE RBC: >100 /HPF
Sugar: NEGATIVE Epithelial Cells: FEW
Ketone: Amorphous: FEW
Blood: Mucus Threads: FEW
Bilirubin: Bacteria: FEW
Urobilinogen: Yeast Cells: FEW
Pregnancy Test:

Others: Crystals:
______________________________ Uric Acid:
Calcium Oxalate:
Remarks: Triple Phosphate:

Hematology
EXAMINATIONS RESULTS REFERENCE VALUES

Hemoglobin 11.9 F: 12-14 g/dL

Hematocrit 0.35 F: 0.37-0.47
RBC Count: 4.20 4.20 - 5.40
WBC Count: 10.7 4.8 - 10.8 x 109L
Differential Count
Segmenters: 80 50-70%
Lymphocyte: 16 25-40%
Eosinophil: 1-4%
Monocyte: 03 3-8%
Band: 01 2-6%
 Basophil: 0-1%

MCV 83.6 80.0-94.0

MCH 28.3 27.0-31.0
MCHC 33.9 32.0-36.0
Platelet Count 23.2 130-450 x 109L
Erythrocyte Sedimentation F: 0-20mm/hr
Rate 1-3 minutes
Bleeding Time 1-6 minutes
Clotting Time
Blood Type
Rh Type

Serology/Immunology
EXAMINATIONS RESULTS

HBsAg NONREACTIVE

Blood Chemistry
TEST NORMAL RANGE RESULT

OGTT

FBS 3.85-5.78 mmol/L 5.34

1 hour < 9.6 mmol/L 6.30

2 hour <8.49 mmol/L 5.25

3 hour <6.10 mmol/L 7.08

OBSTETRICAL ULTRASOUND REPORT

FETUS: PLACENTA:
Number: 1 Location: Anterior
Presentation: Cephalic Grade: 2
Fetal Heart Rate: 139 bpm Distance from int. os: High-
lying

BPD: 8.53cm 34wks 3 days AMNIOTIC FLUID VOLUME: AFI

10.11cm
OFD: 10.74cm 34wks 1 day EDC BY UTZ: March 2, 2020
HC: 31.14cm 34wks 6 days
AC: 29.9cm 33wks 6 days
FL: 6.47cm 33wks 3 days BIOPHYSICAL SCORE:
EFW: 2297 grams Breathing:
Body Movement:
ANATOMICAL SURVEY: Muscle Tone:
Face: Amniotic Fluid Vol.:
Lateral ventricles:
Cerebellum:
Posterior Nuchal Fold:
4-Chamber Heart:
Somach:
Umbilical Cord:
UC Insertion:
Kidney:
Urinary Bladder:
Extremities:

IMPRESSION:
Pregnancy uterine 34 weeks and 1 day by fetal biomer, live singleton in cephalic
presentation with good cardiac and somatic activities. Anterior placenta, grade 2. High-
lying. Adequate amniotic fluid volume
B. Procedures or Treatment done for the patient
Treatment or procedure
➔ IVF of D5LR 1L to run for 8 hours
(2/22/20)
➔ Episiotomy and repair (2/22/20)
➔ IE (2/23/20)
Rationale and Analysis
➔ In NSD, an average of 500ml of blood is
lost. Dextrose in Lactated Ringer's is
administered by intravenous infusion for
parenteral replacement or replenishment of
extracellular losses of fluid and electrolytes.
➔ Episiotomy is a commonly used obstetric
intervention, it is a surgical incision made in the
perineum to help prevent more extensive
vaginal tears during childbirth. Episiorrhaphy is
the surgical repair done with sutures to close
the incision made in the perineum.
➔ A physical exam of the vagina, cervix, uterus,
fallopian tubes, ovaries, and rectum. This is
performed in order to assess any damage and
abnormalities that may cause complications,
such as hemorrhage, infections, etc.
 C. Drug study and analysis

DRUG MECHANISM OF INDICATIONS SIDE/ADVERSE NURSING

ORDER ACTION EFFECTS CONSIDERATIONS

Generic An essential mineral Prevention of ➔ CNS: ● Assess nutritional status

Name: found in hemoglobin, iron deficiency dizziness, and dietary history to
Ferrous myoglobin, and anemia headache, determine possible cause
Sulfate many enzymes. syncope. of anemia and need for
Enters the ➔ GI: nausea, patient teaching.
Brand bloodstream and is constipation, ● Assess bowel function for
Name: transported to the dark stools, constipation or diarrhea.
Anifer, organs of the epigastric pain, ● Toxicity and Overdose:
Hemarate, reticuloendothelial GI bleeding, Early symptoms of
Fersulfate system (liver, spleen, vomiting. overdose include stomach
bone marrow) where ➔ Misc: pain, fever, nausea,
Classificatio it becomes part of temporary vomiting (may contain
n: iron stores. staining of blood), and diarrhea.
Antianemics teeth (liquid ● Explain the purpose of
, iron preparations). iron therapy to patient.
supplements ● Encourage patient to
comply with medication
regimen.
Dosage & ● Advise patient that stools
Route: may become dark green or
60mg, p.o black.
● Instruct patient to follow a
Frequency: diet high in iron.
OD

Generic Cephalexin is a Treatment of ➔ CNS: ● Assess patient for

Name: bactericidal agent the following SEIZURES infection (vital signs;
Cephalexin that stops or slows infections (high doses). appearance of wound,
the growth of caused by ➔ GI: diarrhea, sputum, urine, and stool;
Brand bacterial cells by susceptible abdominal WBC) at beginning of and
Name: preventing bacteria organisms: Skin pain, nausea, throughout therapy.
Ceporex, from forming the cell and skin vomiting. ● Before initiating therapy,
Cefalexin wall that surrounds structure ➔ Derm: rashes, obtain a history to
each cell. infections. urticaria. determine previous use of
Classificatio ➔ Hemat: and reactions to
n: eosinophilia, penicillins or
Anti- hemolytic cephalosporins.
infectives, anemia, ● Observe patient for signs
first- neutropenia, and symptoms of
generation thrombocytope anaphylaxis (rash,
cephalospori nia pruritus, laryngeal edema,
ns ➔ Misc:allergic wheezing).
reactions ● Monitor bowel function
including ● Instruct patient to take
Dosage & anaphylaxis, medication around the
Route: superinfection. clock at evenly spaced
500 mg, p.o times and to finish the
medication completely as
Frequency: directed, even if feeling
q6 better.
 VII. NCP

Assessme Diagnosis Inference Planning Intervention Rationale Evaluation

nt

Subjective: Risk for Local spread of After 2-4 hrs Encouraged the To maintain After 4 hrs. of
colonized bacteria
infection is the most
of proper client to clean proper nursing
“Meron po r/t broken common etiology nursing perform proper perineal area intervention
akong tahi skin for postpartum intervention perineal care free from the goal was
sa pwerta.”- infection
integrity following vaginal
the patient infection met and the
as secondary delivery. will be able Advised to use patient
verbalized to Endometritis is the to: warm water To promote identified 5
by the client most common
episiotomy infection in the
during perineal relief and to interventions
postpartum period. Remain free washing keep it clean. to prevent
Other postpartum of infection as risks of
Objective: infections include
evidenced by Instructed to To prevent infection and
-unable to post surgical
wound infections, stable vital keep the area growth of achieved
perform bacteria and
perineal cellulitis, signs, and clean and dry timely wound
proper mastitis, immediate
absence of healing and
perineal respiratory
healing of
complications signs and free from
care due to
from anesthesia, symptoms of Instructed the stitches . infection.
discomfort retained products client to change
infection.
-improper of conception,
her pad Prolonged
urinary tract Demonstrated
environmen usage of pads
infections (UTIs), Identify at regularly proper
tal and septic pelvic might
least 5 techniques to
sanitation phlebitis. Wound
contaminate promote a safe
infection is more interventions
common with to prevent risk the wound. and clean
cesarean delivery.
of infection. Emphasized the environment.
VS:
importance of To eliminate
T- 36.5 ℃
clean the presence
P- 82 bpm Demonstrate
environment. of rodents
R- 24 proper
and
BP-110/80 techniques to
promote a safe pathogens
and clean that may
environment. cause
contaminatio
n to the
Encourage fluid mother and
intake of 2,000 to
newborn
3,000 mL of water
per day, unless
contraindicated. Fluids promote
diluted urine and
frequent emptying
of bladder –
reducing the
stasis of urine, in
turn, reduces risk
for bladder
infection or
urinary tract
infection.