Nursing Case study nsvd normal spontaneous delivery
NORMAL SPONTANEOUS VAGINAL
Pregnancy, 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: Cesarean section and NSVD or normal spontaneous vaginal
delivery. A cesarean section is a surgical incision through the mother’s abdomen and
uterus to deliver one or more fetuses. NSVD or normal spontaneous vaginal delivery
is the delivery of the baby through vaginal route. It can also be called NSD or
normal spontaneous delivery, or SVD or spontaneous vaginal delivery, where the
mother delivers the baby with effort and force exertion.
Normal labor is defined as the gradual subjugation and dilatation of
the uterine cervix as a result of rhythmic uterine contractions leading to the
expulsion of the products of conception: the delivery of the fetus, membranes,
umbilical cord, and placenta. Laboring cannot that be easy; thereby implicating that
there are processes and stages to be undertaken to achieve spontaneous delivery.
Through which, Obstetrics have divided labor into four (4) stages thereby explaining
this continuous process.
STAGE 1: It is usually the longest part of labor. It begins with regular
uterine contractions and ends with complete cervical dilatation at 10 centimeters.
This stage is broken down into three (3) phases: the Early phase, where the
contractions are usually very light and maybe approximately 20 minutes or more
apart from the beginning, gradually becoming closer, possibly up to five minutes
apart; the Active phase, where contractions are generally four or five times apart,
and may last up to 60 seconds long. Cervix dilates with 4-7 cm and initiates a more
rapid dilatation. It is known that to get through active labor, mobility and relaxations
are done to increase contractions; and the Transition phase, where it is definitely
known as the shortest phase but the hardest, contractions maybe two or three times
apart, lasting up to a minute and a half, about approximately 8-10 cm of cervical
dilatation. Some women will shake and may vomit during this stage, and this is
regarded as normal. Most of the time, women would find a comfortable position to
acquire complete dilatation.
STAGE II: This stage lasts for three or more hours. However, the
length of this stage depends upon the mother’s position (e.g.; upright position yields
faster delivery). Once the cervix has completely dilated, the second stage had
begun. This stage ends with the expulsion of the fetus.
STAGE III: This stage focuses on the expulsion of the placenta from
the mother. Placenta exclusion is much more easier than the delivery of the baby
because it includes no bones, and this is during this stage that the baby is placed on
top of the mother’s womb.
STAGE IV: No more expulsions of conception products for this stage
as this is generally accepted as POST PARTUM juncture. This phase is from the
placental delivery to full recovery of the mother.
Labor and delivery of the fetus entails physiological effects both on
the mother and the fetus. In the cardiovascular system, the mother’s cardiac output
increases because of the increase in the needed amount of blood in the uterine
area. Blood pressure may also rise due to the effort exerted by the mother in order
expel the fetus. There could also be a development of leukocytes or a sharp increase
in the number of circulating white blood cells possibly as a result of stress and heavy
exertion. Increased respiratory may also occur. This happens as a response to the
increase in blood supply in order to increase also the oxygen intake.
Braxton Hicks contractions, or also known as false labor or practice
contractions. Braxton Hicks are sporadic uterine contractions that actually start at
about 6 weeks, although one will not feel them that early. Most women start feeling
them during the second or third trimester of pregnancy. True labor is felt in the
upper and mid abdomen and leads to the cervical changes that define true labor.
With delivery imminent, the mother is usually placed supine with her knees
bent (ie, the dorsal lithotomy position). An episiotomy (an incision continuous with
the vaginal introitus) may be performed at this time. Episiotomy may ease delivery
of the fetal head and allow some control over what may otherwise be an
uncontrolled perineal laceration. However, many providers no longer perform routine
episiotomy, since it may increase the risk of rectal injury and are larger than the
The labor and birth process is always accompanied by pain. Several options
for pain control are available, ranging from intramuscular or intravenous doses of
narcotics, such as Meperidine (Demerol), to general anesthesia. Regional nerve
blocks, such as a pudendal block or local infiltration of the perineal area can also be
used. Further options include epidural blocks and spinal anesthetics.
Nursing Health History
Nursing health history is the first part and one of the most significant aspects
in case studies. It is a systematic collection of subjective and objective data,
ordering and a step-by-step process inculcating detailed information in determining
client’s history, health status, functional status and coping pattern. These vital
informations provide a conceptual baseline data utilized in developing nursing
diagnosis, subsequent plans for individualized care and for the nursing process
application as a whole.
In keeping the private life of my patient and in maintaining confidentiality, let
me hide for with the pseudonym of Patient P.
Patient P was born on December 19, 1992. She was born to parents from
Surigao Del Norte, but she didn’t actually live with them. She was technically
abandoned to the relatives, but those people could not essentially foster her. She
stayed at the Department of Welfare and Social Development or DSWD and spent
her 15 years of existence. Her education was funded mainly by volunteers and
charitable foundations. At the same time, she compensated for it by means of
helping in chores and accomplishing tasks in the said foundation.
She grew up with other abandoned children with questions in her mind. But
to that, she never completely disclosed herself. Patient P is a victim of sexual abuse.
She was raped and was unable to resist because of her innocence. She doesn’t talk
that much. Often times, she paces back and forth inside the ward, sits silently on
her bed and sometimes quietly stares outside the window. When tried to ask about
what she knows of her family, she could only turn silent, and somehow implies to
ask the next question to her. But when chance punched, I grasped it and coiled
directly to my point. Unfortunately, hesitancy was felt from the kind of thing that
was wanted to be discussed. The issue was not forced until her watcher, which has
no relation to her, revealed the reason behind her pregnancy.
According to Patient P’s watcher, it was on a cold night in September 2007,
when Patient P came home from school: Upon nearing the center, a man, which she
identified as a newcomer to the center, blocked and harassed her brutally. She
struggled to let go from the ruthless hands of the unaccustomed man. Patient P was
threatened that if she’d make any noise, she’d get killed. Ill-fatedly, she was held
powerless to the man, and the crime had happened. Fortunate enough that she
wasn’t killed, she thanked the Lord for sparing her life. Although alive, she felt very
much unfair about her situation. She could only tell, “Kabata pa kaayo nako
nahimong inahan, nganong nahitabo man pud ni..” . Patient P conceived the baby
and bore it for 9 months. For the first trimester, she couldn’t believe and accept her
fate, and sometimes thought of slight curses to the person who did the crime. But
somehow, she felt a jot of excitement of a having a baby unexpectedly. She even
verbalized, “Wa naman koy mabuhat. Nahitabo nato. Basin makasala pa kog
ipalaglag nako ang bata.. Wala man siya’y sala.”
According to Erik Erikson’s Developmental Task of adolescence, from the age
of 10 to 18 years old, Patient P belonged to the IDENTITY versus ROLE
CONFUSION, which proposes that the adolescent is newly concerned with how he
or she appears to others. Development mostly depends upon what is done to us.
From here on out, development depends primarily upon what we do. And while
adolescence is a stage at which we are neither a child nor an adult, life is definitely
getting more complex as we attempt to find our own identity, struggle with social
interactions, and grapple with moral issues.
On June 29, 2008, Patient P complained of extreme abdominal pain. On the
same date was her EDC or expected date of confinement. The age of gestation is 39
weeks by LMP. Her LMP was September 2007, exact date unrecalled. She was
admitted to Butuan Medical Center at around 2:40am with blood pressure of 140/90
mmHg. She was examined by Dr. Bombeo and found out that she was fully dilated.
By 2:45am, 5 minutes after her admission, doctor’s orders were carried out:
• #1 D5LR I Liter started @ 20 gtts/min
• TPR q 4°
• CBC blood typing; hbsAg requested
• Labor watch
By 2:55am, she was endorsed to DR wheelchair. With the next 5 minutes,
she was admitted in the ER accompanied by the staff, positioned on the DR table
with final preparation done.
Around 3:36 am, she delivered an alive, 6 lbs 13 oz and 49 centimeters in
length baby girl with these statistics:
• Head Circ: 32 cm
• Chest Circ: 30 cm
• Abd Circ: 20 cm
Extemporaneously, the baby cried with the same breathing time of 3:36am.
Patient P’s placenta was expelled spontaneously by 3:47am with blood pressure of
130/80. Oxytocin 10 units was infused to IVF; Methergine I amp IVTT; her uterus
was firm and contracted and was admitted to ward via stretcher. During her labor,
she was anesthetized with Lidocaine HCl 5cc.
After her delivery, she was admitted to the Ob ward with repaired
episiotomy. Post partum doctor’s orders were as follows which was carried out:
• DAT (Diet as Tolerated)
• Ice pack over hypogastrium
• Perineal care
• Oxytocin 10 U infused to IVF and;
• Methergine I amp IVTT.
• Cephalexin I amp IVTT
• Mefenamic Acid 500mg I cap TID
• May room in
• Breastfeed per demand
Patient P’s temperature was monitored until stable.
On the following day, June 30, 2008, doctor’s order was to secure HBsAg
result. Patient P’s baby was admitted to NICU because of frequent vomiting and
fever. The staff continued to monitor her vital signs and administered prescribed
medications. As a student nurse, I also did my assessment towards my patient’s
condition. Upon assessing, I was able to take and record her vital signs:
• T = 37.3°c
• 82 bpm
• 21 cpm
• 120/70 mmHg
Patient P wasn’t able to take a bath because of her beliefs. Since she has an
episiotomy wound, she is at risk for infection. I made my independent nursing
interventions. I explained to her the importance of proper hygiene to prevent the
occurrence of infection. Emphasis on eating foods rich high protein to promote
wound healing was imparted. She verbalized, “Sakit man akong totoy mam.” So, I
encouraged her to let her baby continuously suck to both breasts when received
back from NICU, that is to relieve her engorgement. Also, I instructed her to
increase fluid intake at least 8 oz per hour to facilitate increase in milk production,
and to eat nutritious foods such as fruits and vegetables to nourish her baby well.
On July 1, 2008, doctor’s orders were noted:
• Continue meds
• Repeat hemoglobin
• MGH after IE and if hemoglobin is OK
By 1:25 pm:
• Defer MGH
• Secure and transfuse 4 units FWB/wg (fresh whole blood)
• Antamine I amp 10,000 units
• BT (blood transfusion)
On the same day, I did my Physical assessment to Patient P and a brief
history about her case. I aided her in securing her blood by persistently going with
her to the blood bank. Patient P was advised to take adequate rest in fear of
hypotension due to her low hemoglobin, 59G/L. So, it was me and her watcher who
was always on the go. I continued to administer her medications per prescription:
• Cephalexin 500mg I cap TID
• Mefenamic Acid 500mg I cap TID
July 2, 2008, doctor’s order was to follow up 4 units of blood. Patient P was
reinserted with IV D5LR.
On July 7, 2008, Patient P was transfused with 4 units of fresh whole blood,
baby was already on mother’s side, and were about to go home. She was seen with
the health workers facilitating her discharge from the hospital.
Physical examination follows a methodical head to toe format in the
Cephalocaudal assessment. This is done systematically using the techniques of
inspection, palpation, percussion and auscultation with the use of materials and
investments such as the penlight, thermometer, sphygmomanometer, tape measure
and stethoscope and also the senses. During the procedure, I made every effort to
recognize and respect the patient’s feelings as well as to provide comfort measures
and follow appropriate safety precautions.
A. General Physical Assessment
Patient is a 15 year old female, stands 5’4, with pulse rate of 82 beats pre
minute, respiratory rate of 21 breathe per minute and a temperature of 37.3 °C. She
is conscious and coherent upon interaction but answers only the questions she is
comfortable with. Most of the time, she is pacing inside the ward and appears
B. Assessment of the Head
Head is round in shape. Hair is long, thick and coarse, straight and evenly
distributed. Scalp is smooth and white in color, minimal lesions were noted. Dandruff
and lice were seen.
C. Assessment of the Eyes
Her eyes are symmetrical, black in color, almond shape. Pupils constricts
when diverted to light and dilates when she gazes afar, conjunctivas are pink.
Eyelashes are equally distributed and skin around the eyes is intact. The eyes
D. Assessment of the Ears
Ears are clean, no ear wax was noted and approximately of the same size
and shape. Patient can hear normally when spoken softly.
E. Assessment of the Nose
With narrow nose bridge, there were discharges noted upon inspection. No
swelling of the mucous membrane and presence of nasal hairs were seen.
F. Assessment of the Mouth
She has a complete set of teeth with minimal dental caries noted. Oral
mucosa and gingival are pink in color, moist and there were no lesions nor
inflammation noted. Tongue is pinkish and is free of swelling and lesions. Lips are
symmetrical, appears pale without bits noted upon observation.
J. Assessment of the Neck
Lymph nodes noted. Neck has strength that allows movement back and forth,
left and right. Patient is able to freely move her neck.
H. Assessment of the Lungs and Thoracic Region
No reports of pain during the inhalation and exhalation. Absence of
adventitious sounds upon auscultation. Respiratory rate 21 breathes per minute
from the normal range of 16-20 breaths per minute.
I. Assessment of the Heart
Patient has an audible heart sound. PMI is heard between 4th - 5th intercostals
space. Heart is pumping well with a pulse rate of 82 bpm from the normal rate of
60-100 beats per minute.
J. Assessment of the Abdomen
Abdominal movement as with respiration, presence of peristalsis during
auscultation. Presence of rashes and lesions.
K. Assessment of the Upper Extremities
Skin: White in color; presence of marks/scars of wounds in the arms, neck
and legs. Skin is smooth, moist and soft to touch.
Hands: Medium in size with 5 fingernails in each side. Nails are short, small
dusty particles are present.
Arms: Able to move through active ROM. Able to extend arms in front or
push them out to the side.
L. Assessment to the Lower Extremities
Size of the feet is undefined with lines on the sole, presence of scars and
lesions. Ten fingers are present. Nails are clean and short. Patient is ambulatory.
M. Assessment of the Genitourinary
With episiotomy dry and intact, urinates 2-4 times a day and has not
defecated yet since her delivery.
N. Assessment of the Perineum
With episiotomy intact, absence of lesions and swelling.
O. Neurological Assessment
Behavior – Patient is silent but is conscious and coherent upon interaction.
She sits and walks if she wants to.
Motor Functioning - Able to move extremities through active ROM.
Able to extend arms front and resist active as pushed
down/up on his hands.
Reflexes - reflexes were present such as the blinking reflex and deep
Sensory Functioning – Patient’s sensory system is intact, she was able to
distinguish touch, pain, hot and cold.
ANATOMY AND PHYSIOLOGY OF THE REPRODUCTIVE SYSTEM
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.
INTERNAL REPRODUCTIVE STRUCTURE
The vagina is a muscular, ridged sheath connecting the external genitals to
the uterus, where the embryo grows into a fetus during pregnancy. In the
reproductive process, the vagina functions as a two-way street, accepting the penis
and sperm during intercourse and roughly nine months later, serving as the avenue
of birth through which the new baby enters the world .
The vagina ends at the cervix, the lower portion or neck of the uterus. Like
the vagina, the cervix has dual reproductive functions.
After intercourse, sperm ejaculated in the vagina pass through the cervix,
then proceed through the uterus to the fallopian tubes where, if a sperm
encounters an ovum (egg), conception occurs. The cervix is lined with mucus, the
quality and quantity of which is governed by monthly fluctuations in the levels of the
two principle sex hormones, estrogen and progesterone.
When estrogen levels are low, the mucus tends to be thick and sparse, which
makes it difficult for sperm to reach the fallopian tubes. But when an egg is ready
for fertilization and estrogen levels are high the mucus then becomes thin and
slippery, offering a much more friendly environment to sperm as they struggle
towards their goal. (This phenomenon is employed by birth control pills, shots and
implants. One of the ways they prevent conception is to render the cervical mucus
thick, sparse, and hostile to sperm.)
The uterus or womb is the major female reproductive organ of humans. One
end, the cervix, opens into the vagina; the other is connected on both sides to the
The uterus mostly consists of muscle, known as myometrium. Its major
function is to accept a fertilized ovum which becomes implanted into the
endometrium, and derives nourishment from blood vessels which develop exclusively
for this purpose. The fertilized ovum becomes an embryo, develops into a fetus and
gestates until childbirth.
The Fallopian tubes or oviducts are two very fine tubes leading from the
ovaries of female mammals into the uterus.
On maturity of an ovum, the follicle and the ovary's wall rupture, allowing the
ovum to escape and enter the Fallopian tube. There it travels toward the uterus,
pushed along by movements of cilia on the inner lining of the tubes. This trip takes
hours or days. If the ovum is fertilized while in the Fallopian tube, then it normally
implants in the endometrium when it reaches the uterus, which signals the
beginning of pregnancy.
The ovaries are the place inside the female body where ova or eggs are
produced. The process by which the ovum is released is called ovulation. The speed
of ovulation is periodic and impacts directly to the length of a menstrual cycle.
After ovulation, the ovum is captured by the oviduct, where it travelled down
the oviduct to the uterus, occasionally being fertilised on its way by an incoming
sperm, leading to pregnancy and the eventual birth of a new human being.
The Fallopian tubes are often called the oviducts and they have small hairs
(cilia) to help the egg cell travel.
Drug Name and Dose Date Ordered Ordering Physician
Cephalexin 500mg 1 cap June 29, 2008 Dr. Bombeo
Mefenamic Acid 500mg 1 June 29, 2008 Dr. Bombeo
GENERIC NAME: CEPHALEXIN
ACTION: Inhibits DNA synthesis by inhibiting DNA gyrase in susceptible gram
negative and gram positive organisms
INDICATIONS: Infectious diarrhea, respiratory tract infection, infection on
the skin structures, bones and joints
CONTRAINDICATIONS: Hypersensitivity to drug or other fluoroquinolones
• CNS: Headache
• CV: Orthostatic Hypotension
• EENT: Blurred Vision
• GI: Nausea and Vomiting, Diarrhea, constipation
• OTHER: Taste
INTERACTIONS: Oral anticoagulants: Increased anti-coagulant effects
• Advise Patient not to take drugs with dairy or Caffeinated
• Inform physician if allergies or rashes abruptly develop
GENERIC NAME: MEFENAMIC ACID
CLASSIFICATION: Anti-Inflammatory, Analgesic
ACTION: Inhibits reuptake of serotonin norepinephrine CNS
INDICATIONS: Moderate to moderately severe pain
CONTRAINDICATIONS: Hypersensitivity with drugs, acute intoxication with
alcohol, physical opioid dependence
• CNS: dizziness
• CV: Vasodilation
• EENT: visual disturbances
• GI: Nausea and Vomiting
• GU: urinary retention
• SKIN: pruritus
• Tell patient that drug works best when taken before pain
• Recommend abstinence from alcohol when taking medication
• Caution patient that drug can cause dependence
Problem # Nursing Diagnosis Date Identified Date Evaluated
1 Risk for infection r/t June 30, 2008 July 1, 2008
tissue 2º to
2 Interrupted breast July 1, 2008 July 1, 2008
feeding r/t infant
3 Situational Low Self- July 1, 2008 Not Evaluated
Esteem r/t perceived
failure at life events
2º to rape trauma
For at least four weeks of duty, I have encountered several constraints
with regards to the implementation of interventions. It was not that easy specially
that what I am dealing with are lives, lives through which if jeopardized, can either
put me in an obnoxious situation or be blameworthy for any complications.
Three days of multi-tasking and time management, the OB-NURSERY
ward exposure has taught me how to appropriately handle pregnant and post
partum women. The idea of caring for mothers and newborns which is not in my
lineage is hard. Hard, because some of the patient’s are uncooperative and non
compliant. It isn’t that smooth to establish an interacting relationship specially that
most of the patient’s admitted in the institution has a low educational attainment.
Therefore, I cannot expect them to fully comprehend the instructions I have
imparted. However, it was a marvelous experience since I was exposed to various
kinds of maternal paragons and procedures which weren’t return demonstrated yet.
Fortunately, there is our clinical instructor who persistently supervised us and
assisted us to make it through with just minimal errors.
Now, let me get this straight. This is my first time to manage an
individual case study. Adding to that is the fear of making a physiologic structure of
my opted case. One false move and I am screwed. I have learned to thoroughly
assess my patient to comply with the requisites. Also, I have acquainted myself with
regards to establishing rapport with my patient to have a trusting relationship. Some
patients do not totally disclose themselves because they may find it privacy invading.
I have learned to be patient and control my feelings of anger or annoyance towards
the patient; to respect and accept their beliefs and values without judging them; to
communicate with them therapeutically; to be accurate and systematic when it
comes to charting to avoid errors and reprimands. Basically, it’s the feeling of
confidence you have in yourself that will facilitate accomplishment and error-free
implementation of nursing care. If you are confident enough to perform the
procedures, then the client will develop trust and confidence to you. The nurse has a
lot of responsibilities to take in, thus, confidence is a very important factor.
The exposure wasn’t centered mainly to rendering care. It was also
focused to building and developing intrapersonal and interpersonal relationships. I
call it, personal growth. To adjust and adapt with the environment is a humongous
task! It’s not that easy. But mingling with other people helps you identify your
strength and weaknesses, and it aids in modifying what is somehow negative in our
attitudes. To sum this all up, it was a SUCCESS! Thanks be to GOD.
The next time that I’ll render care and perform procedures, I will try
to do my best to attain satisfaction and accomplishment.
The materialization of this case study wouldn’t be possible without the
aid of the following folks:
To the Almighty Father for the strength given in realizing and fulfilling
the duties and the study; to beloved parents who have always been supportive all
throughout the start of the duty until the end, the toils and efforts; to dear
comrades and colleagues who have been extending all out help during the rough
scenarios, specially to Miss Sheila Marie Adorador for aiding me in realizing the case
study; and to my groupmates for the overwhelming support, help and
camaraderie, for being cooperative and indulging, that helped me
augment my learning and somehow sharpened my skills.
To our ever lenient but strict clinical instructor, Mr. Paul Ritchie Pelos,
for simplifying what used to be incomprehensible, tricky and complicated
concepts, for assisting us in the various procedures we have performed,
and for being kind to us despite our immaturity
Offenbar haben Sie einen Ad-Blocker installiert. Wenn Sie SlideShare auf die Whitelist für Ihren Werbeblocker setzen, helfen Sie unserer Gemeinschaft von Inhaltserstellern.
Sie hassen Werbung?
Wir haben unsere Datenschutzbestimmungen aktualisiert.
Wir haben unsere Datenschutzbestimmungen aktualisiert, um den neuen globalen Regeln zum Thema Datenschutzbestimmungen gerecht zu werden und dir einen Einblick in die begrenzten Möglichkeiten zu geben, wie wir deine Daten nutzen.
Die Einzelheiten findest du unten. Indem du sie akzeptierst, erklärst du dich mit den aktualisierten Datenschutzbestimmungen einverstanden.