TAGUM DOCTORS COLLEGE, INC.

Mahogany St., Rabe Subd., Visayan Village

Tagum City, Davao del Norte, Philippines
Tel #: (084) 2260127 Email add: [email protected]

A CASE PRESENTATION OF

NORMAL SPONTANEOUS VAGINAL DELIVERY

In partial fulfillment of the requirements in

Related Learning Experience for the Degree of Bachelor of

Science in Nursing

Submitted by:

Submitted to:

Mr. Prince F. Quirante, RN

Clinical Instructor

January 2023
 TABLE OF CONTENTS

Cover Page

Table of Contents

Acknowledgement

I. Introduction

II. Objective

III. Patient’s Data

IV. Family Background/Health History

V. Developmental Data

VI. Definition of Complete Diagnosis

VII. Physical Assessment

VIII. Anatomy and Physiology

IX. Etiology and Symptomatology

X. Pathophysiology

XI. Doctor’s Order

XII. Diagnostic Exam

XIII. Drug Study

XIV. Nursing Theories

XV. Nursing Care Plan

XVI. Discharge Plan

XVII. Recommendation

XVIII. References/Bibliography
 ACKNOWLEDGEMENT

First and foremost, praise and appreciation to God, the Almighty, for His showers of
blessings during our case study, which enabled us to successfully complete it. May his
majesty and strength enlighten us all.

We would like to express our sincerest appreciation to our CI, Mr. Prince F. Quirante,
RN. We will always be indebted to you for your kindness and the wisdom you have shared
with us. The knowledge and understanding you have provided us will act as a lighthouse for
the years to come, and we will cherish and remember them always. To the rest of our Clinical
Instructors, Heidi C. Cabanatan, RN, Roselle B. Baniel, RN, Racuqel R. Donasco, RN, Myka
Allene Ave Catoto, RN, and Nolie Roy E. Biclar, RN, may you lead us on our next clinical
rotation and give us the knowledge and wisdom to become competent nurses in the future.

We will always be grateful to Mrs., our dear Dean of the Nursing Department, for all
the time, patience, and work you have put into helping us become excellent nurses in the
future.

We would want to express our heartfelt thanks to our parents, guardians, and loved
ones for their unwavering support and trust in us, for their love, prayers, caring and
sacrifices for educating and preparing us for our future even through our ups and downs,
our failures, and even the pandemic.

To our group who contributed time, effort, and talent to this project. The time we
spent creating this need will be remembered for the rest of our lives and will be a memory we
will cherish. Thank you for your support and cooperation, this has been a great experience
and none of this would be possible without the aid of anybody, this completed work is the
fruit of our hard works and was accomplished because of everyone, thank you
I. INTRODUCTION
 II. OBJECTIVES

General Objectives

Within our three (3) days of ward exposure at Tagum Doctors Hospital, Inc., we are
able to choose a case study that will contribute to, increase our knowledge of, and hone our
skills in relation to our Maternal and Child Health Nursing on particular procedures. This
case study aims to define Normal Spontaneous Vaginal Delivery (NSVD) and provide a more
thorough understanding of it.

SPECIFIC OBJECTIVES

Our group formulated the following specific objectives, and these will serve as a guide
towards the completion and success of this case study: During the three (3) days of ward
exposure at Tagum Doctors Hospital, Inc., the specific objectives are as follows:

KNOWLEDGE:

 Determine the patient's laboratory and diagnostic tests/examinations and their

indications.
 Analysis of the Anatomical and Physiological landmarks of the involved
organs and system during pregnancy.
 Assess and evaluate the patient's diet history during pre-op to determine the
factors affecting the health of the baby and mother.
 Assess for patient’s complaints and educate her.
 Assess for patient’s opinion, plans and insights after pregnancy

SKILL:

 Develop a nursing care plan for the patient's improvement and complications
in health.
  Perform a comprehensive physical examination of the patient to check for any
anomalies.
 Provide and give advice, ideas, and a treatment plan to the patient regarding
their condition.
 Clarify misconceptions and provide accurate information in simple ways
regarding the patient’s condition.
 Provide different scenarios that will help the patient understand and have more
knowledge about the changes in her life.
 Provide adequate mental support throughout the hospital days.

ATTITUDE

 Additional research and scanning about the background of Normal

Spontaneous Vaginal Delivery, its process, and signs during neonatal,
diagnosis and treatment will widen and improve the student's knowledge and
abilities.
 Explain the various methods and management options for women
experiencing discomfort from Normal Spontaneous Vaginal Delivery.
 Discuss how an integrated care approach may be used to enhance treatment
coordination and outcome for pregnant women undergoing Normal
Spontaneous Vaginal Delivery.
 Develop a coping mechanism that is effective and will be easy for the patient
to acquire.
III. PATIENT’S DATA

A. Biographical Data
 Name: Patient AM
 Birth date: January 5, 1990
 Age: 33-years-old
 Sex: Female
 Birthplace: Kapalong, Davao Del Norte
 Address: Mankilam, Tagum City
 Civil Status: Married
 Religion: Roman Catholic
 Nationality: Filipino
 Educational Attainment: College graduate
 Room Number: Room 516
 Attending Physician: Dr. Lascuna
 Date of Admission: January 25, 2023
 Time of Admission: 4:45 AM
 Date of Discharge: January 28, 2023
 Vital signs upon admission:
▪         BP – 120/80 mmHg
▪         HR – 82 bpm
▪         RR – 19 cpm
▪         T – 36.5
▪         SpO2 – 97%
A. Chief Complaints 

Ms. AM, 33, arrived at the emergency room with the chief complaint of labor

pain with bloody discharge.

a. Admitting/final diagnosis: PU 39 weeks AOG, CIL, G2P1, Intact BOW

b. Final Diagnosis: PU delivered term, Cephalic in Labor, AGA, Female,

SVD, G2P2
b. Surgical procedure (if any): Normal Spontaneous Vaginal delivery with

right mediolateral episiotomy and repair

c. Attending physician: Dr. Lascuna

d. Source of information: Patient’s chart