EMILIO AGUINALDO COLLEGE

1113-1117 San Marcelino St, Paco, Manila

School of Nursing and Midwifery

INTRODUCTION:

A typical spontaneous vaginal delivery (SVD) happens when a

woman gives birth to her child naturally, without the need for forceps,
vacuum extraction, or cesarean surgery, and without the use of medications
or other labor-inducing treatments. The recommended technique of birthing
for mothers whose babies have reached full term is a vaginal delivery.
Nonetheless, women who have already undergone cesarean sections or
who have infections that could be passed on to their unborn child should
not give birth vaginally.

The alternative to vaginal delivery is a cesarean delivery. The majority of

medical professionals advise women whose babies are full term, or at least
37 weeks old, to give birth vaginally. In contrast to other childbirth
techniques like cesarean sections and artificial labor, this type of delivery is
the most straightforward.

A spontaneous vaginal delivery occurs when the baby comes out of the
vagina naturally, without the assistance of medical professionals. After a
pregnant woman experiences labor, her cervix dilates, or opens, to a
minimum of 10 centimeters.

The passage of a woman's mucus plug typically signals the start of labor.
During pregnancy, this mucus clot shields the uterus from bacteria. A
woman's water may rupture shortly after. Another name for this is a rupture
of the membranes. Severe contractions aid in pushing the baby into the
birth canal as labor goes on.

Every woman's labor process is different in duration. First-time mothers

typically experience labor lasting 12 to 24 hours, but those who have given
birth before might only experience
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1113-1117 San Marcelino St, Paco, Manila

School of Nursing and Midwifery

through six to eight hours of labor.

Phase 1:

It typically takes the longest to complete. Regular uterine contractions are

the starting point, and complete ten cm of cervical dilation. Three (3)
phases comprise this stage: the Early phase, where the contractions are
often rather mild and occur anywhere from 20 minutes to more apart from
the beginning, progressively becoming closer, perhaps every five minutes;
the active phase, during which Contractions can last up to 60 seconds and
usually occur four or five times apart. Cervix dilates between 4 and 7 cm
and starts a faster dilation. It is well known that in order to get through
active labor, contractions are induced by mobility and relaxation
techniques. In the Transition phase, which is unquestionably the shortest
but hardest phase, contractions can occur up to three times a minute,
resulting in a cervical dilatation of 8 to 10 cm. Some women might tremble
and throw up.at this point, and it is thought to be typical. Women would
typically locate a comfortable position to achieve full dilation.

Phase 2:

Three hours or longer are spent in this phase. But the mother's posture
affects how long this phase lasts (for example, an upright posture results in
a quicker delivery). The second phase starts when the cervix has fully
dilated. The fetus is expelled at the end of this stage.

Phase 3:

The placenta's departure from the mother is the main focus of this stage.
Placenta removal is significantly more simpler than giving birth because
there are no bones involved, and it is at this stage that the infant is
positioned above the mother's womb.
 EMILIO AGUINALDO COLLEGE
1113-1117 San Marcelino St, Paco, Manila

School of Nursing and Midwifery

Phase Four:

Since this is often considered to be the POSTPARTUM juncture, there will

be no additional expulsions of conception products at this point. This stage
spans the time from the mother's placental delivery until her full recovery.

Both the mother and the fetus experience physiological changes during
labor and delivery. Because more blood is required in the uterine area, the
mother's cardiac output increases, which affects the cardiovascular system.
The mother's efforts to push out the fetus may also cause blood pressure to
rise. In addition, leukocytes may form or the quantity of white blood cells in
the blood may noticeably rise as a result of stress or strenuous activity.
Enhanced respiration can also happen. This occurs as a result of an
increase in oxygen consumption brought on by an increase in blood supply.
False labor or practice contractions are other names for Braxton Hicks
contractions.

GENERAL OBJECTIVES

The purpose of this group case study was to increase our

understanding of Normal as student nurses. Spontaneous Vaginal Delivery
by gathering enough data that could act as a roadmap for us to improve our
knowledge, abilities, and attitudes around postpartum care and the
breastfeeding process patient care for a normal spontaneous delivery.

SPECIFIC OBJECTIVE

● to obtain information about the client's personal background, family

history, previous and present medical history, and physical
examination utilizing 13 assessment domains.
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1113-1117 San Marcelino St, Paco, Manila

School of Nursing and Midwifery

● to go over the female reproductive system's anatomy, physiology, and

postpartum modifications.
● to compare the diagnostic procedure outcomes to the expected
values.
● to design the usual spontaneous delivery medication trial.
● to create a nursing care plan that works and the client can benefit
from.
● should create a postpartum discharge strategy in order to maintain
continuity of care.

II. Patient Profile

1. PERSONAL DATA:
OB WARD
NAME: Patient Y
CASE NUMBER: 082221
DATE OF BIRTH: May 26, 1995
PLACE OF BIRTH: Alabang, Muntinlupa City
ADDRESS: Ayala Westgrove Heights
AGE: 28 yrs. old
STATUS: Married
RELIGION: Roman Catholic
DATE ADMITTED: August 2, 7:22 am
CHIEF COMPLAINT: Watery vaginal discharge for 12 hours, Labor
pain
FINAL DIAGNOSIS: G1P1, Pregnancy uterine delivered
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1113-1117 San Marcelino St, Paco, Manila

School of Nursing and Midwifery

spontaneously to a term cephalic live baby by APGAR score: 8.9

Baby’s weight 2.6 kg

Environmental Status: She lived in an urban area wherein pollution is

very common. They live in a concrete house with 6 occupants. In her
hospitalization, she felt some discomfort because of the setting, two
people sharing a single bed. According to her, the room is too
crowded for her to have some quality time to rest but she was aware
the time she was interviewed in the
emergency room.

Lifestyle: Patient Y described her habits by watching TV all the time

and using her smartphone for social media. She was very lazy all the
time as she stated. She didn’t even try to engaged herself to prenatal
exercises but she clearly states that she had regular check-ups. “Lagi
lang ako sa bahay, nakahiga nanunuod, cellphone,ganun kaya siguro
nahirapan ako sa panganganak”, as verbalized.

III. PATIENT HISTORY

Patient Y has been married to Mr. Z for a year. She has two siblings
and is the oldest member of the family. They don't have enough money on
their own to afford a house of their own, so they temporarily reside with
patient Y's parents. Her 15-year-old younger sister was born with a
congenital cardiac condition. Her mother and younger sister both had
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1113-1117 San Marcelino St, Paco, Manila

School of Nursing and Midwifery

asthma, which is now under control, and her father had a history of
hypertension for which he currently takes maintenance medication.

3. History of past illness

Patient Y experienced some common colds before she got

pregnant. She has no allergy to any medications or foods. She completed
her pre-natal check-ups and she is regularly taking her ferrous sulfate
supplement. During her 7 months of conception, she experienced UTI and
she immediately went to her doctor and gave her cefalexin. She completed
the prescribed dose and she felt better on the following days. She has a
regular menstruation, and she also experienced dysmenorrhea. She has
no history of bleeding and any discomfort on her pregnancy until she begun
to labor and delivered her first baby.

4. Present health history

Few hours prior to admission patient Y had a watery vaginal

discharge for 12 hours. She was admitted with a chief complaint of labor
pain with watery vaginal discharge. Her second stage of labor lasted for 20
minutes and the third stage lasted for 5 minutes. At 10:32 am she delivered
an alive baby boy via Normal spontaneous delivery. She had to undergo an
episiotomy to widen the opening of her vagina (primigravida) with 200cc
blood loss based on her chart. After the post-natal and early postpartum
care in the delivery room, she was transferred to OB- service ward via
stretcher. She was conscious and had no complications throughout the
delivery.

1. STATUS SOCIAL
Mrs. Y was born in Alabang, Muntinlupa City on May 26, 1995,
making her 28 years old. She and her family lives in Ayala Westgrove
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1113-1117 San Marcelino St, Paco, Manila

School of Nursing and Midwifery

Heights. They follow Roman Catholicism. Mr. Z, He works as a Medical

Doctor and is 29 years old. Their money allowed them to pay for Mrs.Y
developed laziness during her pregnancy. But before working at the
Hospital alongside her spouse. They intended to become parents. On
August 2, 7:22:21AM, Mrs. Y was admitted.(G1P1).

NORMS:
Social status includes family ties, which indicate the patient's network of
support under stressful situations. and when necessary. It satisfies a basic
human need for social connections, reducing stress and Social support
mitigates the damaging effects of stress, which tangentially promotes
health results. Barbara Kozier, "Fundamentals of Nursing," sixth edition

ANALYSIS:
Mrs. Y enjoys a positive relationship with her family because they were
extended relatives. Mrs. Y, together with his husband has enough savings
to cover Mrs. Y's hospital stay.

2. EMOTIONAL STATUS
Mrs. Y is helpful and cooperative during the interview. Her spouse
said that they are overjoyed to have their first child. She also talks about
how she felt about the delivery; initially, she was upset with herself for not
pushing the baby correctly in the delivery room, which led to the need for
an episiotomy. However, after seeing her child, she started to feel worthy of
herself because she was now a mother and had responsibilities to fulfill.

NORMS:
According to Mary Ellen Zator Estez's Health Assessment and Physical
Examination, the young adult years are a period of independence and
separation from the family as well as obligations, responsibilities, and
accountability in social, professional, and domestic roles and relationships.
 EMILIO AGUINALDO COLLEGE
1113-1117 San Marcelino St, Paco, Manila

School of Nursing and Midwifery

ANALYSIS:
Mrs. Y is aware of her health status. They both said that they are eager to
have children, which is why they are grateful for their blessings. Mrs. Y
experiences Erickson's industry vs. inferiority because she learns self-worth
as she becomes proficient in psychological and physiological
Modifications.

3. NUTRITIONAL STATUS
Mrs. Y can identify wholesome food, but she can't always use it. She
eats three times a day, interspersed with snacks. When she was pregnant,
her husband brought her fruits. She weighed 48 kg before becoming
pregnant, and during that time she put on 4 kg. She consumes a range of
veggies, however primarily meats for lunch. She does not have a food
allergy.

NORMS:
The Health Asian Diet Pyramid recommends consuming rice, grains, bread,
and fruit every day and veggies; optional every day for seafood, shellfish,
and dairy products; mandatory every week for desserts, eggs, and
monthly for meat and poultry. A rise in the consumption of a wide range of
fruits and veggies. Add foods high in omega-3 fatty acids and vitamins C
and E to your diet.

ANALYSIS:
She has a normal eating pattern

4. ELIMINATION
During the delivery, Mrs. Y had one bowel movement. She had a
pinkish-colored voiding episode once prior to delivery due to blood in the
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1113-1117 San Marcelino St, Paco, Manila

School of Nursing and Midwifery

urine. Urinary tract infection (UTI) was a former medical condition for her.
The perineal incision causes her discomfort every time she voids.

NORMS:
A person should normally avoid three to four times a day and have one to
two bowel movements each day.having a daily production of 1200–1500
ml. Normal stools are well-formed and brown in color, and urine is clear.
should have a golden hue. (Kozier, Fundamentals of Nursing, 2007)

ANALYSIS:
Due to a slow peristalsis movement following delivery, Mrs. Y experienced
a delayed bowel movement. The patient should have a timely bowel
movement within 24 hours.

5. REPRODUCTIVE STATUS
Her reproductive organs have undergone some changes, particularly
the exterior parts (Episiotomy and episiorrhaphy), however because of the
distribution method, it is regarded as typical. Her menstrual cycle was
regular. She has the potential to become pregnant again because no birth
control was mentioned throughout the conversation.

NORMS:
All bodily systems are impacted by the regular physiological process of
pregnancy, which produces both subjective
As objective shifts, it's a demanding period that calls for several
adjustments and could result in small discomforts.

ANALYSIS:
Mrs. Y marked the physiologic changes of pregnancy hence, reproductive
status is altered but expected to return to normal status after 1 month
(approximately)
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1113-1117 San Marcelino St, Paco, Manila

School of Nursing and Midwifery

6. STATE OF PHYSICAL REST AND COMFORT:

Mrs. Y usually sleeps 6-8 hours at night, she stated that

sometimes her sleep is interrupted because of the discomfort due to her
perineal incision. By the help of her cousin and her husband they
simultaneously taking care of the baby as Mrs. S take her rest periods.

NORMS:
Adults' average amount of sleep per day is 7 to 8 hours.

ANALYSIS:
She consumed the 7 to 8 hours sleep, but the only thing is she felt irritated
because of her perineal
Incision.

7. ANATOMY AND PHYSIOLOGY OF FEMALE AND MALE

REPRODUCTIVE SYSTEM
OVARIES
● The ovaries are the ultimate life-maker for the females.
● For its physical structure, it has an estimated length of 4 cm and
width of 2 cm and is 1.5 cm thick. It appears to be shaped like an
almond. It looks pitted, like a raisin, but is grayish white in color.
● It is located proximal to both sides of the uterus at the lower
abdomen.
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1113-1117 San Marcelino St, Paco, Manila

School of Nursing and Midwifery

● For its function, the ovaries produce, mature, and discharge the egg
cells or ova. Ovarian function is for the maturation and maintenance
of the secondary sex characteristics in females.
● It also has three divisions: the protective layer of epithelium, the
cortex, and the central medulla.

FALLOPIAN TUBE
● The fallopian tubes serve as the pathway of the egg cells towards the
uterus.
● It is a smooth, hollow tunnel that is divided into four parts: the
interstitial, which is 1 cm in length; the isthmus, which is2 cm in
length; the ampulla, which is 5 cm in length; and the infundibular,
which is 2 cm long and shaped like a funnel.
● The funnel has small hairs called the fimbria that propel the ovum into
the fallopian tube.
● The fallopian tube is lined with mucous membrane, and underneath is
the connective tissue and the muscle layer.
● The muscle layer is responsible for the peristaltic movements that
propel the ovum forward.
● The distal ends of the fallopian tubes are open, making a pathway for
conception to occur

MALE REPRODUCTIVE
● Scrotum: This is the loose pouch-like sac of skin that hangs behind
and below the penis. It contains the testicles (also called testes), as
well as many nerves and blood vessels. The scrotum acts as a
"climate control system" for the testes. For normal sperm
development, the testes must be at a temperature slightly cooler than
body temperature. Special muscles in the wall of the scrotum allow it
to contract and relax, moving the testicles closer to the body for
warmth or farther away from the body to cool the temperature.
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1113-1117 San Marcelino St, Paco, Manila

School of Nursing and Midwifery

● Testicles (testes): These are oval organs about the size of large
olives that lie in the scrotum, secured at either end by a structure
called the spermatic cord. Most men have two testes. The testes are
responsible for making testosterone, the primary male sex hormone,
and for generating sperm. Within the testes are coiled masses of
tubes called seminiferous tubules. These tubes are responsible for
producing sperm cells.
●
● Epididymis: The epididymis is a long, coiled tube that rests on the
backside of each testicle. It transports and stores sperm cells that are
produced in the testes. It also is the job of the epididymis to bring the
sperm to maturity, since the sperm that emerge from the testes are
immature and incapable of fertilization. During sexual arousal,
contractions force the sperm into the vas deferens.

● Vas deferens: The vas deferens is a long, muscular tube that travels
from the epididymis into the pelvic cavity, to just behind the bladder.
The vas deferens transports mature sperm to the urethra, the tube
that carries urine or sperm to outside of the body, in preparation for
ejaculation.

● Ejaculatory ducts: These are formed by the fusion of the vas deferens
and the seminal vesicles (see below). The ejaculatory ducts empty
into the urethra. Urethra: The urethra is the tube that carries urine
from the bladder to outside of the body. In males, it has the additional
function of ejaculating semen when the man reaches orgasm. When
the penis is erect during sex, the flow of urine is blocked from the
urethra, allowing only semen to be ejaculated at orgasm.

● Seminal vesicles: The seminal vesicles are sac-like pouches that

attach to the vas deferens near the base of the bladder. The seminal
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1113-1117 San Marcelino St, Paco, Manila

School of Nursing and Midwifery

vesicles produce a sugar-rich fluid (fructose) that provides sperm with

a source of energy to help them move. The fluid of the seminal
vesicles makes up most of the volume of a man's ejaculatory fluid, or
ejaculate.

● Prostate gland : The prostate gland is a walnut-sized structure that is

located below the urinary bladder in front of the rectum. The prostate
gland contributes additional fluid to the ejaculate. Prostate fluids also
help to nourish the sperm. The urethra, which carries the ejaculate to
be expelled during orgasm, runs through the center of the prostate
gland.

● Bulbourethral glands: Also called Cowper's glands, these are

pea-sized structures located on the sides of the urethra just below the
prostate gland. These glands produce a clear, slippery fluid that

8. DIAGNOSTICS AND LABORATORY PROCEDURE

● Pelvic Ultrasound Report (Biophysical Profile)
Date: 11/7/2023
Name: Patient Y
Age:28
Pertinent data: 39 weeks by LMP (+) watery vaginal discharge
BIOPHYSICAL PARAMETERS
No. of Fetus: Singleton Fetal Breathing: 2
Presentation: Cephalic Fetal Movement: 2
Fetal Heart Rate: 142 bpm Fetal Tone: 2
Amniotic Fluid Volume: 7.8 cm Amniotic Fluid Index: 2
Placenta-Location: Anterior Non-Stress Test: 2
Grade-3 Total score= 10/10
Distance from the OS- no previa
BIOMETRY NON- BIOMETRIC PARAMETERS
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1113-1117 San Marcelino St, Paco, Manila

School of Nursing and Midwifery

BPD: 85 mm = 34 2/7 wks Cerebellum: 5.1 cm- 37 weeks

HC: 305 mm = 34 wks Colonic Grade: 2
AC: 316 mm = 35 4/7 Distal Femoral Epiphysis: (+)
FL: 68 mm = 35 wks Proximal Humeral Epiphysis: (-)
Mean Ultrasonic Age: 35 4/7
Estimated Fetal Weight: 2598 grams ( 5 lb 12 oz)
Ultrasonic EDD: 12/14/16
4 QUADRANT AFI: 2.7 cm, 0. 2.8 cm, 2.2 cm
IMPRESSION:
PREGNANCY UTERINE, 34 WEEKS 5 DAYS AOG BY FETAL BIOMETRY.
LIVE, SINGLETON FETUS IN CEPHALIC PRESENTATION, MALE.
ANTERIOR PLACENTA GRADE 3, NO PREVIA.
RELATIVELY LOW AMNIOTIC FLUID VOLUME.
GOOD FETAL TONE. ACTIVE FETAL BREATHING AND MOVEMENT.
REACTIVE NON-STRESS TEST. BIOPHYSICAL PROFILE SCORE:10/10
Please correlate clinically and with earliest scan.

Dr. Arminda Calayan

OB-GYN Sonologist

IV. PHYSICAL ASSESSMENT

Vital Signs
During the postpartum period, women may exhibit a slight
temperature elevation due to dehydration following delivery or as a
result of breast milk coming in around day 3 or 4. Immediately after
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1113-1117 San Marcelino St, Paco, Manila

School of Nursing and Midwifery

delivery, the blood pressure should remain the same as during

delivery. An increase in blood pressure could indicate gestational
hypertension (previously referred to as pregnancy-induced
hypertension), while a decrease could indicate shock or orthostatic
hypotension. Slight bradycardia is normal immediately after delivery;
however, tachycardia could indicate hemorrhage or infection and
should be monitored carefully. Respirations are usually within the
normal range for an adult.

Pain
During the postpartum period, it is very important that healthcare
providers continually assess a patient for pain, taking into account the
patient’s acceptable pain levels. They should look for pain in all areas
of the body, including the head, chest, breast, back, limbs, abdomen,
uterus, perineum, and extremities.Positioning during labor may cause
muscular discomfort, and headaches can indicate gestational
hypertension. Patients should also be assessed for emotional pain
and treated accordingly. Mild analgesics or narcotics may be
prescribed. Providers can also teach nonpharmacologic methods of
pain relief to the patient and her family. Some of these methods
include the application of hot or cold packs, massage, progressive
relaxation, and meditation.

V. NURSING PROBLEM

PROBLEM: Labor pain

NURSING DIAGNOSIS: Risk for infection
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1113-1117 San Marcelino St, Paco, Manila

School of Nursing and Midwifery

VI. NURSING CARE PLAN

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1113-1117 San Marcelino St, Paco, Manila

School of Nursing and Midwifery

VII. DRUG STUDY

VIII. DISCHARGE PLANNING

Breastfeeding:
● Wash breast with lukewarm water daily for cleanliness. Air dry
nipples after each feeding. If breasts are engorged, apply warm
packs and express milk. Practiced feeding per demand. Uterine
Changes: After pains, or cramping are normal. This cramping
means that the uterus is contracting to return to its
non-pregnant size. The uterus takes 5-6 weeks to return to its
non-pregnant size.
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1113-1117 San Marcelino St, Paco, Manila

School of Nursing and Midwifery

Vaginal Discharge
● Usually lasts about 10 days t0 4 weeks. The color will change
from bright red to brownish to tan and will become in
approximately 6-8 weeks, unless breastfeeding.

● Maintain good perinial and personal hygiene by taking a bath

every day.
● Menstruation : Periods will resume in approximately 6-8 weeks,
unless breastfeeding.

Care of Episiotomy Sitz Bath:

● sitting in a tub of warm water for 15 minutes, 2-3 times per day
will help relieved the discomfort.

● Keep the area clean and dry to speed up the healing process.

● Stitches will dissolve in 1-3 weeks.

Diet and Nutrition

● Continue taking prenatal iron and vitamin pills until the
post-partum visit.

● It is important to eat well-balanced diet and drink plenty of

fluids. Drink two quarts of fluid per day if you are breastfeeding.

Post-partum Visit

● Follow the allotted date of post-partum visit thus the post-natal

check-ups.
EMILIO AGUINALDO COLLEGE
1113-1117 San Marcelino St, Paco, Manila

School of Nursing and Midwifery