LABOR AND DELIVERY

CASE SCENARIO 3: Belle

Belle came in to the Hospital accompanied by her mother because of labor pain that started 5
hours ago. Cervix is dilated 3cm, 50% effaced. Membranes is intact. Fetal Heart Tone is 140
beats per minute. Fetus is in cephalic presentation as revealed in ultrasound. Uterine
contraction is moderate to strong in intensity with duration of 45 seconds and with an interval
of 3 minutes. Upon assessment bladder is distended. She was encouraged to void. Place on
NPO while in active labor. IVF of D5LR 1L. to run at 30gtts/min..

 Belle presented her laboratories results as follows:

1. CBC
A. Hgb   __________ 142g/L
B. Hct   __________ 0.41 Vol. Fr
C. RBC   __________ 4.41 x 10ͮ^12/L
D. WBC  __________ 6.4 x 10^g/L

1. Urinalysis-

 Physical Properties
Color Straw
Transparency Hazy
Reaction 5.0 (acidity)
Specific Gravity 1.025
Chemical Tests
Sugar Negative
Albumin Negative
Microscopic Findings
Pus Cells Occasional 0-3
RBC Occasional 2-4
 

Vital Signs revealed as follows;

Temperature 37.1°C
Pulse Rate   88 bpm
Respiratory Rate 20 cpm
Blood Pressure 130/80 mmHg
FHB 140 bpm

Belle hold her abdomen, screams and shout, “Why does this hurt so badly”, I wish my boyfriend
is here.

After 3-4 hours from admission Belle complains of increased uterine contractions.With intensity
occurring every 2-3 min. and with a duration of 60-70sec. Bloody show and rupture of the
membranes noted. Internal examination done revealed 10 cm. cervical dilatation.

Belle transferred to delivery room per stretcher. She complaints the urge of bearing down. After
an hour she delivered to an alive baby girl via NSVD.
Questions:

1. Interpret the vaginal examination done to Belle when she came in the lying in
clinic based on the record presented in the scenario (3cm, 50%effaced).
Answer:
Belle has reached 3cm dilation, indicating that she is in the early stages of labor. Belle's
cervix progressively dilates to around 6cm during this stage. This is the most time-
consuming stage of labor, lasting anywhere from 8 to 12 hours. Belle's bag of water
rupture and mucousy vaginal discharge are apparent at 3cm dilation, as are regular
contractions that get harder and more frequent. Belle's cervix is roughly 2cm long since
it is 50% effaced. It's halfway to becoming short and thin enough to allow the baby to
pass through the uterus and into the vaginal canal. The majority of effacement occurs
during the first stage of labor. Early indications of labor, like as Braxton Hicks
contractions and the loss of Belle's mucus plug , are likely to accompany it. The period
between contractions varies from five to thirty minutes, and each one lasts around 30 to
45 seconds. IE is used to determine the dilation and effacement of a pregnant woman.

2. Ultrasound of Belle revealed cephalic presentation. Explain cephalic

presentation?
Answer:
Cephalic presentation, this is the ideal position for labor, especially if the baby is head
down, facing your back, chin tucked, and the rear of the head is ready to enter the birth canal
in the womb. The cephalic presentation helps the infant move through the delivery canal as
easily and safely as possible. When the fetus is in a noncephalic position, it is more difficult to
deliver the baby. Different fetal positions provide a variety of challenges, and the dangers differ
based on your child's position.

3. Belle’s duration of uterine contraction lasted 45 seconds with an interval of 3

minutes. Discuss the stages and phases of labor she experienced.
Answer:
The duration of a uterine contraction is the time it takes from start to finish. The contraction
between the end of one contraction to the start of the next is known as the interval. Belle's
length was 45 seconds, with a 3 minute gap, indicating that she is having fake uterine
contractions rather than real contractions. She went through the first stage of dilation, which
starts when actual labor contractions begin and concludes when the cervix is fully dilated.
4. Why do we advise the mother on NPO during labor?
Answer:
The risk of aspiration, which occurs when food or drink is inhaled into the lungs, has long
been cited as a reason why women should fast during delivery. During labor, pulmonary
aspiration of stomach contents is a significant cause of maternal morbidity and death. Women
who require obstetric surgery and general anesthesia are at a higher risk.

5. FHR was checked and revealed 140 beats per minute. What is a normal fetal
heart rate during labor? 
Answer:
During labor, a baby's heart rate should be between 110 to 160 beats per minute, although
it may be higher or lower for a variety of reasons. Short bursts of increased heart rate in the
infant are typical and signal that the baby is obtaining enough oxygen. When the baby's head is
squeezed while in the delivery canal, brief decelerations in the baby's heart rate are also typical.
If these accelerations or decelerations do not occur at the expected times, or if they are
protracted, it might indicate a variety of concerns, including a squeezed umbilical cord and
delayed blood supply to the baby.
6. Ms. Belle presented her laboratories. What is the normal reference value?
Discuss the significance if it is elevated and decreased result during pregnancy.
Normal reference value
Urinalysis
General Chemistries
Color : straw
Turbidity : Clear
pH: 5-9
Specific Gravity: 1.003 – 1.030
Protein: negative
Glucose: Negative
Ketone: Negative
Bile: Negative
Urobilinogen Trace to 1 mg/dL
Blood – Negative
Leokocyte Esterase: Negative
Nitrate- Negative
WBS: 4.5 TO 11.0
RBC: 3.80 TO 5.20
Hgb: 117-161 (12.1-15.1)
Hct: 0.35 to 0.47

Belle’s presented Laboratories

Urinalysis-

 Physical Properties
Color Straw
Transparency Hazy
Reaction 5.0 (acidity)
Specific Gravity 1.025
Chemical Tests
Sugar Negative
Albumin Negative
Microscopic Findings
Pus Cells Occasional 0-3
RBC Occasional 2-4

Answer:

All laboratories Belle undergone are all normal since she is on labor. Her urine appear
Hazy because of the influence of ruptured amniotic fluid and the acidity is normal also because
amniotic fluid is one of the factors that affect it’s result. To some up all results are normal.

7.  State and discuss psychological behavior presented in the scenario as verbalized

by Ms. Belle.
Answer:
Physical and psychological obstacles such as coping with pain, losing control, and perhaps
medical interventions are all present throughout labor and birth (e.g., episiotomies, forceps or
vacuum extraction, C-sections). Given that she is primipara, Ms. Belle's psychological behavior
of doubting labor pains and seeking treatment for a partner is typical, thus the only option for
her to relieve labor pain is to scream and distract herself. It was discovered that the behaviors
displayed by women in labor had an impact on their pains during delivery, and that there was a
link between the length of labor stages and the degree of pain. In order to obtain a good
clinical treatment, it was suggested that attention be paid to the actions of women in labor.
8. Identify and discuss the stage of labor in the progress of uterine contractions of
Ms Belle presented in the case scenario.
Answer:

The First Stage (Dilatation)

When belle start to experience regular contractions when belle come to the hospital with
uterine contraction is moderate to strong in intensity with duration of 45 seconds and with an
interval of 3 minutes. The cervix opens (dilates) and softens, shortens, and thins. This is the
first stage of labor and birth (effacement). This makes it possible for the infant to enter the
delivery canal. The first stage is the most lengthy of the three.

After 3-4 hours from admission Belle complains of increased uterine contractions. With intensity
occurring every 2-3 min. and with a duration of 60-70sec. Bloody show and rupture of the
membranes noted. Internal examination done revealed 10 cm. cervical dilatation.

This indicate transition phase:

 Contractions reach their peak on intensity occurring every 2 to 3 minutes with a duration
of 60 to 70 seconds.
 A maximum cervical dilatation of 8 to 10 cm
 If it has not previously occurred, show will occur as the last of the mucus plug from
the cervix is released
 If the membranes have not previously ruptured they will usually rupture at full
dilatation (10 cm)
 Both full dilatation (10 cm) and complete cervical effacement (obliteration of the
cervix) have occurred
 A woman may experience intense discomfort that is strong, it may accompanied by
nausea and vomiting
 She may also experience a feeling of loss of control, anxiety, panic and/or irritability
 A new sensation, the irresistible urge to push usually begins.

Belle transferred to delivery room per stretcher. She complaints the urge of bearing down.
After an hour she delivered to an alive baby girl via NSVD. Is an indication of 2 nd Stage of labor
which start from the full dilation until the infant is born. To be followed by the 3 rd stage of labor
which is the delivery of the placenta and 4 th stage of labor which after 1-4 hours of the birth of
the placenta.

9. As crowning occur, is episiotomy applicable to Ms. Belle? Why?

Answer:
Episiotomy the surgical incision of the perineum is done when there is already
perineal bulging (crowning).In the case of Belle since she is primigravida episiotomy is
applicable.

10. What is Ritgen Maneuver? Explain the indication in performing Rirgen Manuever?
Answer:
Ritgen Manuevering is a technique for assisting a fetus in achieving extension so that the head
is delivered with the lowest diameter. The rate at which the head is born is also controlled by
this. Because uterine rupture is a possibility, pressure should never be applied to the fundus of
the uterus to induce labor. Only to use Ritgen´s maneuver in case of labor arrest or abnormal
fetal heart rate pattern when the fetal head was at the pelvic floor.

11. Enumerate and briefly discuss the 2 types of episiotomy

Answer:
There are two types of episiotomy incisions:
  Midline (median) incision. A midline incision is done vertically. A midline incision is
easier to repair, but it has a higher risk of extending into the anal area. Easy repair and
faster healing are two advantages of a midline episiotomy. This form of episiotomy is
also less painful, and it is less likely to cause long-term discomfort or pain problems
during sexual activity. A midline episiotomy is also associated with reduced blood loss. A
midline episiotomy's major drawback is the greater possibility of rips extending into or
through the anal muscles. Long-term consequences of this sort of damage include fecal
incontinence, or the inability to regulate bowel motions.

 Mediolateral incision. A mediolateral incision is done at an angle. A mediolateral

incision offers the best protection from an extended tear affecting the anal area, but it is
often more painful and is more difficult to repair. The major benefit of a mediolateral
episiotomy is the reduced likelihood of anal muscle rips. However, there are a slew of
other drawbacks to this form of episiotomy, including,Increased blood loss causes more
intense pain and makes healing more difficult.Long-term pain is more likely, especially
during sexual intercourse.

12.Explain are the mechanisms of labor?

Answer:
The mechanisms of labor are descent, flexion, internal rotation, extension, external rotation,
and expulsion.

The passage of your baby's head past the bony section of the pelvis and into the deep part of
the pelvic cavity is known as "descent."

Flexion:. The head of your baby pushes on the pelvic tissue during flexion, orienting their head
with their chin toward their chest.

Internal rotation: your baby's head and body rotates from side to side, front to back, to
traverse the shifting diameters of the pelvis.

Extension: When the head has completed internal rotation and passed through the pelvis at the
nape of the neck, the neck rests under the pubic arch. When the head, face, and chin are born,
they extend.

External rotation: There is a brief break in the movement of labor after your baby's head is
delivered. Your baby will rotate from face-down to 90 degrees and face one of your thighs
during this interval.

Expulsion: Your baby's body rotates with the head, allowing the top and then bottom shoulders
to emerge. Because of the tiny size of the infant, the rest of the baby is readily delivered once
the shoulders are delivered.

13.Enumerate and explain the signs of placental separation.

Answer:
The mother will have severe uterine pains when the placenta separates. She will feel the desire
to bear down as the placenta descends down the delivery canal, and she will push the placenta
out.

The most reliable sign is the lengthening of the umbilical cord as the placenta separates and is
pushed into the lower uterine segment by progressive uterine retraction. Placing a clamp on the
cord near the perineum makes it easier to appreciate this lengthening. Never place traction on
the cord without countertraction on the uterus above the symphysis; otherwise, one may
mistake cord lengthening due to impending prolapse or inversion for that of uncomplicated
placental separation.

The uterus gets firmer and more globular in form. As the placenta falls into the lower section
and the uterus's body continues to withdraw, something happens. Clinically, this shift may be
difficult to notice.

The uterus rises in the abdomen. The descent of the placenta into the lower segment, and
finally into the vagina, displaces the uterus upward.
A gush of blood occurs. As the placenta descends to the lower uterine section, the
retroplacental clot is free to escape. The retroplacental clot generally develops in the center and
exits after full separation; but, if the blood can find a way out before complete separation, it
may do so before complete separation, making it a poor indication of complete separation.
Increased bleeding and a longer third stage are occasionally linked with this event, which
occurs when the leading edge of the placenta and maternal surface are delivered first
(Matthews Duncan technique), rather than the cord insertion and fetal surface, which is more
frequent (Schultze method).

14. Formulate a nursing care plan base on Ms. Belle

Defining Nursing Outcome Nursing Rationale Evaluation
Characteristic Diagnosi Identification Interventio
s s n
“Why does this Acute Pain Longterm: Independent:
hurt so badly”, related to After a month Instruct the To minimize Goals met as
as stated by the physical after the delivery patient how the labor the labor
patient. agent of the infant the to do pain of the pain of the
“Nurse ga sakit such as patient will able breathing patient. patient
na akon busong labouring to verbalize and techniques to minimize
daw mabata na , as understand the minimize pain Repositionin after the
ako” as evidenced pain she felt of labor. g and back nurse
verbalized by by self- during labor. rubbing to a demonstrate
the patient. report of Discuss signs of Instruct the client on d the proper
intensity . labor onset, how patient labor can breathing
“Araguy, nurse to distinguish significant ease the techniques
indi nagid between false other to do pain as well and other
maangwantaha and true labor, back and leg as the client pain relief
n ang kasakit when to notify rubs, on labor measures.
kag mabata na healthcare repositioning know that
ako” as provider, and of patient as she is Patient able
verbalized by when to leave for demonstrated supported to
the patient. birth by nurse. by her understand
center/hospital as Respect significant. contractions
Objective: appropriate; and client during labor.
Urine: stages of labor contraction To give time
Transparency and delivery. This time to the Goals met as
 Hazy helps ensure Dependent: patient to laboratory
LMP: June timely arrival and Carry out the adjust to result in
16,20211 enhances coping doctors order frequency,
with the during interval,
EDD: March 23, labor/delivery delivery of duration and
2022 process. the infant intensity of
and follow up labor
Short term: laboratories
Report pain is once the To monitor
minimized/relieve infant is the patients
d as the nurse delivered. and infants
demonstrate condition
 behaviors and during labor
techniques such and delivery.
as breathing,
back or leg rubs
and repositioning,
back rest that her
significant other
can use to assist
with pain control
and relaxation.

Defining Nursing Outcome Nursing Rational Evaluation

Characterist Diagnosis Identificati Intervention e
ics on
Subjective: Deficient Long term: Independent:
“Why does Knowledge After health Nurse must assure For the Goals met as
this hurt so regarding teaching is that the client client to the patient
badly”, as preparation for given the absorbs the health provide verbalized
stated by the labor and client will be teaching given. appropria understanding
patient. delivery, infant able to gain Demonstrate/ te care to regarding to
“Nurse ga care may be knowledge supervise infant the new labor and
sakit na akon related to lack about labor care activities born. delivery and
busong daw of exposure or and delivery related to feeding infant care
mabata na experience, for her next and holding; To after the
ako” as misinterpretati pregnancy. bathing, diapering, maintain health
verbalized by ons of After the and clothing; care safety teaching
the patient. information, discharge of umbilical cord and given
possibly plan the stump; and care of avoid Verbalize
“Araguy, evidenced by client able to circumcised male infection understanding
nurse indi request for know the infant to the of care
nagid information, child care. Nurse should newborn. requirements
maangwanta statement of Client will be monitor clients to promote
han ang concerns, aware of the interaction to the .To health of self
kasakit kag misconception stages of infant. establish and infant.
mabata na s. labor after skinship To promote
ako” as the Discuss available to the an
verbalized by admission. community mother understanding
the patient. support and the of the
Short term groups/parenting infant. principles and
Objective: Inform client class as indicated techniques of
Urine: about the To newborn
Transparency discomfort improve care, fosters
 Hazy she would Dependent: clients parents’ skills
LMP: June felt during Carry out doctors knowledg as caregivers,
16,20211 labor stage. order such as e about and enhances
giving medicine for childreari self- confi
EDD: March after pains. ng dence.
23, 2022 The presence
of bonding
acquaintance
behaviors
(e.g., making
eye contact,
using a high-
pitched voice
and en face
[face- to-
 face] position
as culturally
appropriate,
calling infant
by name, and
holding infant
closely) are
indicators of
beginning
attachment
process

Discuss
available
community
support
groups/parent
ing class as
indicated

15. Base on this findings formulate 2 nursing diagnosis

Answer:

 Acute Pain related to physical agent such as labouring , as evidenced by self-

report of intensity .
 Deficient Knowledge regarding preparation for labor and delivery, infant care
may be related to lack of exposure or experience, misinterpretations of
information, possibly evidenced by request for information, statement of
concerns, misconceptions
Defining Nursing Outcome Nursing Rationale Evaluation
Characteristic Diagnosi Identification Interventio
s s n
Subjective: Acute Pain Longterm: Independent:
“Why does this related to After a month Instruct the To minimize Goals met as
hurt so badly”, physical after the delivery patient how the labor the labor
as stated by the agent of the infant the to do pain of the pain of the
patient. such as patient will able breathing patient. patient
“Nurse ga sakit labouring to verbalize and techniques to minimize
na akon busong , as understand the minimize pain Repositionin after the
daw mabata na evidenced pain she felt of labor. g and back nurse
ako” as by self- during labor. rubbing to a demonstrate
verbalized by report of Discuss signs of Instruct the client on d the proper
the patient. intensity . labor onset, how patient labor can breathing
to distinguish significant ease the techniques
“Araguy, nurse between false other to do pain as well and other
indi nagid and true labor, back and leg as the client pain relief
maangwantaha when to notify rubs, on labor measures.
n ang kasakit healthcare repositioning know that
kag mabata na provider, and of patient as she is Patient able
ako” as when to leave for demonstrated supported to
verbalized by birth by nurse. by her understand
the patient. center/hospital as Respect significant. contractions
appropriate; and client during labor.
Objective: stages of labor contraction To give time
LMP: June and delivery. This time to the Goals met as
16,20211 helps ensure Dependent: patient to laboratory
timely arrival and Carry out the adjust to result in
EDD: March 23, enhances coping doctors order frequency,
2022 with the during interval,
labor/delivery delivery of duration and
process. the infant intensity of
and follow up labor
Short term: laboratories
Report pain is once the To monitor
minimized/relieve infant is the patients
d as the nurse delivered. and infants
demonstrate condition
behaviors and during labor
techniques such and delivery.
as breathing,
back or leg rubs
and repositioning,
back rest that her
significant other
can use to assist
with pain control
and relaxation.
 Defining Nursing Outcome Nursing Rational Evaluation
Characterist Diagnosis Identificati Intervention e
ics on
Subjective: Deficient Long term: Independent:
“Why does Knowledge After health Nurse must assure For the Goals met as
this hurt so regarding teaching is that the client client to the patient
badly”, as preparation for given the absorbs the health provide verbalized
stated by the labor and client will be teaching given. appropria understanding
patient. delivery, infant able to gain Demonstrate/ te care to regarding to
“Nurse ga care may be knowledge supervise infant the new labor and
sakit na akon related to lack about labor care activities born. delivery and
busong daw of exposure or and delivery related to feeding infant care
mabata na experience, for her next and holding; To after the
ako” as misinterpretati pregnancy. bathing, diapering, maintain health
verbalized by ons of After the and clothing; care safety teaching
the patient. information, discharge of umbilical cord and given
possibly plan the stump; and care of avoid Verbalize
“Araguy, evidenced by client able to circumcised male infection understanding
nurse indi request for know the infant to the of care
nagid information, child care. Nurse should newborn. requirements
maangwanta statement of Client will be monitor clients to promote
han ang concerns, aware of the interaction to the .To health of self
kasakit kag misconception stages of infant. establish and infant.
mabata na s. labor after skinship To promote
ako” as the Discuss available to the an
verbalized by admission. community mother understanding
the patient. support and the of the
Short term groups/parenting infant. principles and
Objective: Inform client class as indicated techniques of
LMP: June about the To newborn
16,20211 discomfort improve care, fosters
she would Dependent: clients parents’ skills
EDD: March felt during Carry out doctors knowledg as caregivers,
23, 2022 labor stage. order such as e about and enhances
giving medicine for childreari self- confi
after pains. ng dence.
The presence
of bonding
acquaintance
behaviors
(e.g., making
eye contact,
using a high-
pitched voice
and en face
[face- to-
face] position
as culturally
appropriate,
calling infant
by name, and
holding infant
closely) are
indicators of
beginning
attachment
process

Discuss
available
community
support
groups/parent
ing class as
indicated