Normal

Spontaneous
Vagina Delivery
Group 11: Case Presentation
Clinical Scenario/Actual Case

Demographic
Profile
Name: Villanueva, Ariene Boongaling
Age: 26 years old
Weight: 54 kg
Address: D. I. Calihan San Francisco S.P.C.
Gender: Female
Marital Status: Single
Date of Admission: December 6, 2022
Time of Admission: 7:50am
Definition of Disease/Clinical Situation

How a pregnant women feel?

Implantation
Fertilization
Zygote

Blastocyst Decidua Fetal

Formation of
Trophoblast Fetal Development
Chorionic Villi

Stages of Labor
Process of Labor
Normal Spontaneous
Delivery
IV. ASSESSMENT

A. Physical B. System
Assessment Assessment

D. Diagnostic
C. Laboratories Procedures
Generic/Brand Name Classification / Side Effects / Adverse Nursing Consideration Patient Teaching
Indication  Reaction
Oxytocin  Pharmacologic class: CNS: seizures, coma, neonatal * Continuously monitor * Inform the patient about the
  Posterior brain damage, subarachnoid contractions, fetal and risks and benefits of
(Pitocin, Syntocinon, pituitary hormone hemorrhage maternal heart rate, oxytocin-induced labor.
Syntometrine)     and maternal blood pressure  
Therapeutic class: Uterine- CV: premature ventricular and ECG. * Teach patient to recognize
active agent contractions, arrhythmias, Discontinue infusion if and
neonatal bradycardia uterine hyperactivity occurs. immediately report adverse
    drug effects
GI: nausea, vomiting * Monitor the patient
  extremely closely
GU: post-partal hemorrhage; during the first and second
pelvic stages of labor because of
hematoma; uterine hypertonicity, the risk of cervical laceration,
spasm, or tetanic contraction; uterine rupture, and maternal
abruptio placentae; uterine and fetal
rupture (with death.
excessive doses)  
  * When giving drugs to
Hematologic: afibrinogenemia control post
  partal bleeding, monitor and
Hepatic: neonatal jaundice record
Other: hypersensitivity reactions vaginal bleeding.
including anaphylaxis, low 5-  
minute
Apgar score (neonate), * Assess fluid intake and
output. Watch
for signs and symptoms of
water
intoxication.
VI. Treatment (Pre Natal Medication)

Folic Acid (Vitamin B9)

Ferrous Sulfate
Hemarate FA (Antianemic)
Calcium Supplement
Supplement
 Assessment Diagnosis Goals and Interventions Evaluation
Outcome
         
 Continued uterine  Laboring  To deliver the  Assessed the vital  The patient does not
contraction patient fetus signs of the patient. experience any head
  successfully   ache, visual
 Irritability  Performed internal disturbances and does
  examination (IE) not show any swelling
 V/S taken as   on the face nor hands.
follows  Assisted the patient
  everything she needed
o T: 36.5 to go to the comfort
o P: 95 room ex. Putting on
o R:19 diapers.
o BP: 100/60  
   Established rapport.
   
   Teach the patient the
proper way of
breathing.
 
 Massaged the
abdomen to help the
placenta detach.
 
 
 FOCUS DATA ACTION RESPONSE
November 28, 2022 • Ms. Boongaling lab result shows that her • Patient is prescribed with Hemarate FA and take it 3 times daily. • By November 29, 2022, her latest

Hypotension hemoglobin is 9.6 that is below in the normal range. To ensure that she will increase her hemoglobin and can have hemoglobin is 9.9. it shows that

normal delivery taking 3 times a day Hemarate FA

is effective for the patient to

increase her hemoglobin

December 06, 2022 • Ms. Boongaling is alert, awake, and oriented to • Patient is encouraged to ambulate. Perform a back rub to apply • The patient ‘s face grimaced. Pain

2:00pm person, time, and place. Her chief complaint of counter pressure and help ease back pain. Demonstrate proper persists and increases when

Labor Pain labor pain is characterized by radiating pain from breathing techniques. Encourage the patient to express her ambulating.

the lower back to the abdomen, which is relieved emotions and offer support throughout the labor process. 

when walking and sitting. The pain appears every

4-5 minutes after one hour. 

December 06, 2022 •In from delivery room, 26 years old, G4P3 in active • Placed on DR table in lithotomy position • • Procedure well tolerated

3:36pm labor •Perineal Preparation done aseptically

For normal delivery •With IV fluid of D5Lrs infused with oxytocin. •Episiotomy done by Ma'am Nerie thru local anesthesia

•Provided physical and psychological support to the mother

•Delivered spontaneously to an alive baby girl weighing 2.4kg at

3:36pm

•Placenta delivered completely through Schultze method