BATAAN PENINSULA STATE UNIVERSITY

MAIN CAMPUS www.bpsu.edu.ph

College of Nursing and Midwifery
bpsucnm_2007@yahoo.com
City of Balanga, 2100 Bataan
2016@gmail.com

NAME: Cataina, Maria Elizabeth D. Section: BSN 2A Group: 03

CASE STUDY : LABOR AND DELIVERY

Situation :

Mrs. Maria Dela Cruz 28 years old, gravida 3, para 2, was admitted at term at 6:30pm. She stated that
she had been having contractions at 7-10 minute intervals since 4pm. They lasted 30 seconds. She also
stated that she had been having a lot of false labor and hope that these was the real thing. Her
membranes were intact. Vital signs as follows: temperature: 36.7C, pulse rate; 76bpm, respiratory rate,
20bpm, blood pressure 120/80mmHg, fetal heart tone: 138bpm. . The nurse examined Mrs. Dela Cruz
and found that the baby’s head was at +1 station, and the cervix was 4cm dilated and 80 percent
effaced. Her LMP was July 21, 2021. According to her, all her children was born at term at all living with
her.

Answer the following questions:

1. Compute for EDC and AOG using the date today.

DOC: December 13, 2021 (12-13-21)

LMP: July 21, 2021 (7-21-21)

7 21 21 August - 31
-3 +7 +1 September - 30
4 28 22 --> EDC: April 28, 2022 October – 31
November – 30
December – 13
July (31 – 21) - 10
AOG = 145 / 7 = 20 WEEKS, 5 DAYS

2. Compute for GTPAL

G–3
T–2
P–0 (G3T2P0A0L2)
A–0
L–2
3. Do you think Mrs. Maria Dela Cruz is in false labor? Justify your answer
Based on the given information of the client’s condition and presentation, she is already
in true labor. Her contractions for 30 seconds are at 7-10 minutes interval, which are signs of the
latent phase of labor. The contraction also seems to stay in that pattern for many times already
for the patient to have determined and recognize the interval of each pain. A sign of true labor is
regular interval of contractions. The head of the baby is also at +1 station which indicates that
the baby is engaged. The effacement is at 80%.
 BATAAN PENINSULA STATE UNIVERSITY
MAIN CAMPUS www.bpsu.edu.ph
College of Nursing and Midwifery
bpsucnm_2007@yahoo.com
City of Balanga, 2100 Bataan
2016@gmail.com

4. Mrs. Maria Dela Cruz was getting into bed, her membranes ruptured. What is the first thing that
you would do after this occurs? Explain your answer
The first thing to do is to inform the attending physician (OB-GYNE) of the patient of
what happened. Then observe the color and the smell of the amniotic fluid to check for signs of
any possible abnormalities or infection in the patient’s uterus or placenta. Also, check the
increase in the effacement, dilation, contractions. Monitor the baby’s placement or station of
engagement.

5. After her membranes ruptured, her contractions began coming every 4 minutes and lasted for
45 to 55 seconds. They were moderately strong. Why it is important to Mrs. Dela Cruz to relax
during her contractions? How can you help her to relax?
Mrs. Dela Cruz is still at the first stage of labor at this point. It is important for her to
relax during this stage despite the pain so she can conserve energy that she will need later to
push the baby during expulsion stage.
Some interventions we can encourage to help the patient relax are breathing exercises,
distraction method (encouraging the participation of the spouse in this method is helpful to
relieve the patient and distract her attention from the pain), therapy through the of music or
imagery, assisting the client to assume comfortable position or upright maternal positions if
tolerated.

6. How would you know that Mrs. Dela Cruz has entered the transition phase?
When the patient has entered the transition phase, the dilation of the cervix should be 8
to 10 cm with full (100%) effacement. The patient is either exhausted or more aggressive and
has the urge to push. Crowning is also present. Her contractions will occur every 2-3 minutes
lasting up to 60-90 seconds. The patient may also experience nausea and vomiting.

7. A vaginal examination revealed that Mrs. Dela Cruz cervix is at 10cm dilated. What should be the
nursing intervention at this time?
- Listen frequently (every 5 minutes) to the fetal heart in between contractions to detect
bradycardia.
- Encourage active pushing whenever the urge to bear down arises.
- Observe progressive descent and rotation of the presenting part. This includes observing
progressive distension of the perineum and visibility of the presenting part, and vaginal
examination especially where progress appears to be slow.
- Be ready to augment contractions with an intravenous oxytocin infusion during the second
stage where contractions have become infrequent and where the fetal heart rate remains
normal, to avoid the need for instrumental vaginal delivery or transfer.
- Check the maternal pulse and blood pressure, especially where there is a pre- existing
problem of hypertension, severe anemia, or cardiac disease.

8. Why it is important to put identification on the baby in the delivery room.

 BATAAN PENINSULA STATE UNIVERSITY
MAIN CAMPUS www.bpsu.edu.ph
College of Nursing and Midwifery
bpsucnm_2007@yahoo.com
City of Balanga, 2100 Bataan
2016@gmail.com

It is important to put identification, correct and complete, on the baby in the delivery
room for correct identification. Name tags of newborns are very important to avoid
identification mistakes which may cost the life of either or both the baby and the parent, such as
administering wrong medication, wrong diagnosis, and/or swapping in returning infants to
couples.

9. What nursing care should Mrs. Dela Cruz receive before she is transferred to the recovery room.
Expound your answer.
After the delivery of the placenta,
- administering oxytocin to prevent uterine atony
- assess vital signs (especially blood pressure and heart rate due to risk of hemorrhage and an
increased temperature due to risk of infection)
- observe bleeding and discharge to prevent hemorrhage and blood loss.
- assess the fundus of the uterus for firmness
- observe the genitalia for tears
- Perineal care is the term applied to the external irrigation or cleansing of the vulva and
perineum and anal region as a means of preventing infection, promoting healing of the
stitched perineum, and making the patient comfortable.

References:

Contractions and signs of labor. (n.d.). from https://www.marchofdimes.org/pregnancy/contractions-

and-signs-of-labor.aspx#

Management of the second stage of labor. (2012). International Journal Of Gynecology &

Obstetrics, 119(2), 111-116. doi: 10.1016/j.ijgo.2012.08.002

Unit 9 episiotomy and nursing management. (n.d.). from

https://egyankosh.ac.in/bitstream/123456789/32125/1/Unit-9.pdf

Stages of Labor Nursing NCLEX Review. (n.d.). from https://www.registerednursern.com/stages-of-

labor-nursing-nclex-review/

Stages of Labor: Nursing Care Tips for Various Stages. (n.d.). from https://nurseslabs.com/stages-of-
labor/