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Normal Spontaneous Delivery
Normal Spontaneous Delivery
Delivery
A. BACKGROUND OF THE STUDY
STAGES OF LABOR
Patients in labor are usually admitted to the hospital during the first
stage of labor. It is important to differentiate between the active and latent
phases because women admitted in latent labor tend to spend more time in
the labor ward and have more interventions than those whose admission is
delayed until the active phase. When a patient is admitted during the latent
phase, physicians should set reasonable expectations for labor progress to
avoid unnecessary interventions and anxiety. In GBS-negative women who
are at term, admission to the labor ward should be delayed until the active
phase of labor begins.
Fetal heart rate monitoring during labor has become common in the
United States; it was used in 85 percent of deliveries in 2002, used to
determine the well-being of the fetus. Fetal electrocardiogram (ECG)
monitoring is a newer technology that has shown potential because it
reduces acidosis and the need for operative vaginal delivery when used as
an adjunct to continuous fetal heart rate monitoring.
During the second stage of labor, the fetus descends through the
maternal pelvis and is ultimately expelled. Tremendous stress is placed on
the passageway, often resulting in trauma to the genitourinary tract, most
commonly the perineum. Spontaneous tears that require suturing occur in
approximately one third of women in the United States, and anal sphincter
tears occur in less than 1 percent.
Reduction in perineal trauma is desirable because affected women
have an increased risk of long-term perineal pain, long-term dyspareunia,
urinary problems, and fecal incontinence. Antenatal perineal massage can
reduce the need for laceration repair or episiotomy, and can reduce
prolonged pain in women without prior vaginal delivery. Although these
benefits were modest, the technique has no known deleterious effects and
may be beneficial in some primigravidas.
During the third stage of labor, the uterine muscle must contract
adequately to slow maternal blood loss once the placenta separates from the
uterine wall. A prolonged third stage of labor, which is diagnosed after 30
minutes if spontaneous placental delivery does not occur, may require
further intervention.
Purpose
Precautions
During the postpartum period the mother is at risk for such problems
as infection, hemorrhage, pregnancyinduced hypertension, blood clot
formation, the opening up of incisions, breast problems, and postpartum
depression.
The initial phase of the postpartum period encompasses the first one
to two hours after delivery. It takes place most often in the birthing room or
in a recovery room. Once this initial phase is over, the woman has passed
through the most dangerous part of childbirth. Assessments of pain, the
condition of the uterus, vaginal discharge, the condition of the perineum, and
the presence/absence of bladder distension (followed by appropriate
interventions) are part of the initial postpartum evaluation; and should be
done every 15 minutes for the first hour, then generally every 30 minutes for
the second hour, and every four to eight hours thereafter depending on
facility policy.
A plugged duct can also cause breast pain. Breast pain caused by a plugged
duct is distinguished from breast engorgement by the fact that it is usually
confined to one breast and the breast is not warm to the touch. This pain
may be relieved by heat packs, gentle massage of the breast toward the
nipple, and changing positions for nursing the baby.
If massaging the uterus does not result in a firming of the fundus, then the
physician or nurse-midwife should be contacted immediately. The existence
of severe atony or a retained fragment of placenta may result in excessive
loss of blood.
When the perineal area is examined, the patient should also be checked for
the presence of a hematoma (a round area filled with blood) that is caused
by the rupturing of small blood vessels on the surface of the perineum.
After observing the perineum, the rectal area also is evaluated for
hemorrhoids, making note of their size, character, and number.
Application of cold packs to the perineum for the first 24 hours after
delivery.
Application of warm packs to the perineum after the first 24 hours.
Rinsing of the perineal area with warm water after every void and/or
bowel movement. (This is also helpful in preventing infection and in
promoting healing.)
Use of anesthetic sprays and creams. Cleaning the area with witch
hazel pads (Tucks) is also soothing.
Sitting in a sitz bath—a small basin that fits on top of the toilet through
which warm water flows—three or four times a day. After discharge a
woman may use her bathtub at home for this purpose.
Case:
A 17 year old primigravida was admitted to the hospital for labor pain
at 41 weeks age of gestation. She does not have any complications during
her pregnancy. She delivered her baby via normal spontaneous delivery
without difficulty on expulsion of the fetus and the placenta. She was
diagnosed as gravida 1 para 0 with a TPAL score of 1001 pregnancy uterine
full term, cephalic in labor. Ms. Kate delivered a healthy baby girl at her
young age. During her experience at the delivery room she stated that it was
difficult and painful but as soon as she saw her baby she seems relieved and
ready to face the entity of the new world for them. Upon admitted at the OB
ward she seems very exhausted and in pain due to the delivery, uterine pain
and episiotomy.
I chose the case of Ms. Kate as part of my study to know better about
normal delivery and its prior complications among postpartum primigravida
woman. As part of our curriculum it is better for us, student nurses, to be
alert and aware of those cases regarding the risk factors during labor and
delivery, and to have a valid and frequent nursing management that we can
do during postpartal period of our client and how we can implement our
interventions especially to the first time mothers.
B. RATIONALE (Objectives)
General Objective:
Specific Objectives:
To promote safety and comfort of the client during the recovery period.
To give the appropriate discharge plan to the client for a continuous
and successful recovery outside the hospital.
To broaden my knowledge as a student nurse by doing an in-depth
research about normal spontaneous delivery.
To impart knowledge to the client as to the importance of living a
healthy lifestyle in order to avoid any further complications.
This case study can be very beneficial to many people. First is the
Student Nurses which are able to establish good communication skills with
the patient, family and staff, obtain knowledge about the disease in order to
provide necessary care and health teachings to the patient and the family
and also to provide necessary actions to prevent and cope with the disease
and last but not the least is to become competent and critical nurses. Second
are the Clinical Instructors/ Staff Nurses which they identify the
deficiency of this study, to obtain necessary information regarding the
patient and her condition, to give more knowledge and ideas for more
effective and reliable case study and to be able to obtain methods for better
discussions. And third but not the least is the Patient / Family which them
to have a full understanding about her current condition, to gain knowledge
as to the proper management of health during the recovery period. For the
family, to learn all the necessary information about the proper care of the
patient after discharge to ensure the full recovery of the patient
I received the client last August 19, 2010 from the delivery room and I
monitored the vital signs of the patient together monitoring her IV fluid in
every hour, checking her fundus if the uterus was contracted and firm. I also
monitored the amount of blood being discharged in the vagina to know if
there was any sign of hemorrhage. We started from 6 o’clock in the morning
until 2 in the afternoon. I continued my care the next day August 20, 2010 by
assisting the client doing her perineal care and doing morning care for her
baby girl. We were the ones who gave her the medication on time for her to
be more relieved about her pain. For our 8 hours of duty I ensured Ms. Kate’s
safety. Our group also gave health teachings to Miss Kate, so that after she
was discharged she knew how to care herself even though without the need
of neither nurse nor physicians.
E. THEORETICAL FRAMEWORK
B. CHIEF COMPLAINT
Ms. Kate’s complaint was labor pain upon admission and
experienced vaginal and uterine pain after delivery and upon admitted
to the OB ward.
C. PSYCHOSOCIAL HISTORY
Ms. Kate is a typical teenager who is always happy and outgoing.
Even though she is brought up well, her decision making was greatly
influenced by her boyfriend and friends. She experienced her first
coitus at the age of 15, without thinking of the consequences of this
action. Now that she just gave birth at 17 years old, she does not see
this as a problem. She does not fully understand the responsibilities
that come with motherhood.
F. OBSTETRICAL HISTORY
Ms. Kate was a Gravida 1 Para 1 with a TPAL score of 1001. She
was 41 weeks age of gestation and delivered her baby through NSD
upon her last menstrual period last November 4, 2009. Her mother
delivered them in Normal Spontaneous Delivery and not encountered
any complications. Her menstrual period before she got pregnant
occurred monthly with no problems occurring. Her menstrual flow was
normal and last for 3 to 4 days without experiencing dysmenorrhoea.
G. FAMILY HISTORY
As of the family history of Ms. Kate, there was no record of any
diseases in her family. She stated that no history of illness involve in
their race. There family have complete immunization and has no
allergy encountered.
I. Head
VI. Cognitive- The Patient’s vision The Patient’s five The patient is
Perceptual Pattern is normal, the eyes senses are in experiencing pain
is brown in color. normal condition. because of the
She does not But she is birthing process.
experience any experiencing pain
pain in her daily on her uterine and
activities. She episiotomy area.
stated that on their
school they had a
medical checkup
every year. This
stated that she
was healthy
physically.
VII. Self-Perception The patient The patient was The patient was
and Self-Concept describes herself practicing to be a trying to be a good
Pattern as a simple person. good mother to her and great mother
She lives her life as baby. For her, the when it comes to
a teenager. Before only strength that her baby. She
getting pregnant she could have becomes mature
her only strength now is her baby. as she saw her
was her boyfriend She had a fear that child. She realizes
and her weakness her baby might get the consequences
was her study, sick in which may that she had done
when her parents give her the before getting
persuade her not weakness. pregnant.
to study.
VIII. Role- The patient was The patient role The patient role as
Relationship the second of three now is to be a good women was
Pattern children of her mother to her child change to a
parents. The most and to be a good responsible mother
important person wife to her for her child and
for her was her husband. As a wife for her
family and young one she was husband.
boyfriend. She trying to cope on
does household her new role as a
chores. The main new mother of
problem occurs reality.
when her parents
find out that she
got pregnant at a
young age and at
first she had been
disowned by her
family for quite
some time but had
been accepted.
X. Coping-Stress The Patient copes The patient’s life The Patient is lucky
Tolerance Pattern with her problems had big changes. to have a strong
with the help of As a teenager she support system in
was now facing the her mother despite
her mother. Her
world of hardship. the difficulties she
mother was the She does not is facing in life.
one supporting her regret anything
when she had that she had done.
problems regarding The only strength
her studies. that she was
holding to cope on
the situation is her
baby and the
support of her
mother.
J. LABORATORY EXAMINATION
HEMATOLOGY
M: 40-54%
F: 37-47%
Neutrophils Neutrophils
89% above normal
range could
50-70 % indicate
common
finding with
Lymphocytes acute bacterial
11% infections.
25-40% Decreased
lymphocytes
Blood Type may indicate
Rh BT “O” viral infections
+
A, B, AB, O
,+
A. Mons Veneris
• A pad of adipose tissue located over the symphisis pubis, the pubic
bone joint.
B. Labia Minora
C. Labia Majora
D. Vestibule
• The space wherein we can see the vaginal and uretral opening.
E. Clitoris
F. Skene’s Gland
PARAURETRAL GLANDS
INTERNAL STRUCTURES
A. Ovaries
• Almond shaped
• Produce, mature and discharge ova
• Initiate and regulate menstrual cycle
• 4 cm long, 2 cm in diameter, 1.5 cm thick
• Produce estrogen and progesterone
B. Estrogen
C. Fallopian tubes
• Approximately 10 cm in length
• Arises from each corner of the uterine body
• Conveys ova from ovaries to the uterus
• Site of fertilization
• Parts: interstitial
• isthmus – cut/sealed in (Bilateral Tubal Ligation)
• ampulla – site of fertilization
• infundibulum – most distal segment; covered with fimbria
D. Uterus
E. Uterine Wall
G. Fornices
• Uterine end of the vagina; serve as a place for pooling of semen
following
coitus.
• Bulbocavernosus – circular muscle act as a voluntary sphincter at the
external opening to the vagina (target of Kegel’s exercise).
PLACENTA
CIRCULATION
• The fetus is connected by the umbilical cord to the placenta, the organ
that develops and implants in the mother's uterus during pregnancy.
• As early as the 12th day of pregnancy, maternal blood circulation
begins to collect in the intervillus spaces of the uterine endometrium
surrounding the chronic villi.
• By the 3rd week of pregnancy, through the blood vessels in the
umbilical cord, the fetus receives all the necessary nutrition, oxygen,
and life support from the mother through the placenta..
• From there, the nutrients are being transported back to the growing
embryo.
• Waste products and carbon dioxide from the fetus are sent back
through the umbilical cord and placenta to the mother's circulation to
be eliminated.
The blood from the mother enters the fetus through the vein in the
umbilical cord. It goes to the liver and splits into three branches. The
blood then reaches the inferior vena cava, a major vein connected to
the heart.
• Blood enters the right atrium, the chamber on the upper right side of
the heart. Most of the blood flows to the left side through a special
fetal opening between the left and right atria, called the foramen
ovale.
• Blood then passes into the left ventricle (lower chamber of the heart)
and then to the aorta, (the large artery coming from the heart).
• From the aorta, blood is sent to the head and upper extremities. After
circulating there, the blood returns to the right atrium of the heart
through the superior vena cava.
• About one-third of the blood entering the right atrium does not flow
through the foramen ovale, but, instead, stays in the right side of the
heart, eventually flowing into the pulmonary artery.
• Because the placenta does the work of exchanging oxygen (O2) and
carbon dioxide (CO2) through the mother's circulation, the fetal lungs
are not used for breathing. Instead of blood flowing to the lungs to pick
up oxygen and then flowing to the rest of the body, the fetal circulation
shunts (bypasses) most of the blood away from the lungs. In the fetus,
blood is shunted from the pulmonary artery to the aorta through a
connecting blood vessel called the ductus arteriosus.
DRUG STUDY
Medication
Date treatment Action Indication Nursing
Ordere Drug Dose Responsibility
d Frequency
DRUG STUDY
Medication
Date treatment Action Indication Nursing Responsibility
Ordere Drug Dose
d Frequency
MEDICATION
The Patient and the relatives are provided information about the time
of medication to be taken as ordered by her doctor.
Instruct and explain to the patient that the medication is very
important to continue depending on the duration that the doctor
ordered for the total recovery of the patient.
Ensure that that client will follow doctor’s order regarding taking
medications at home.
Methergin 1 tab TID x 3 days
Cefuroxime 500 mg 1 tab x 7 days
Mefenamic Acid500 mg 1 cap TID for pain
Inavit PO once a day for 30days
FeSO41 cap OD x 30 days
EXERCISE
TREATMENT
Advise patient to boil guava leaves for perineal care as it helps speed
up the healing process
HEALTH TEACHING
OUTPATIENT
Advice client to come back a week after her discharge to have a follow-
up treatment as doctor’s advice.
DIET
Teach patient to eat foods rich in protein to repair the cells that was
damaged and helps in production of antibodies, which fight against
infection and illness, and is the main nutrient that keeps our hair shiny
and healthy, our nails strong, our skin fresh and glowing and our bones
strong and healthy protein rich foods will promote faster wound
healing.
Encourage also the patient to increase her intake of foods rich in iron
because iron is necessary to make hemoglobin, the substance that
carries oxygen through your blood to all the cells in your body and fiber
because it keeps the natural digestive processes working right. When
functioning properly, your body is better able to absorb valuable
nutrients, and keep you running smoothly and foods rich in fiber can
avoid constipation.
Encourage patient to increase fluid intake up to 3 liters.
SPIRITUAL
The Patient and the significant others are advised to have a deep Faith
to Divine God for Guidance and Always Pray.