Philippine Rehabilitation Institute
NORMAL
SPONTANEOUS DELIVERY
G2 P2
CLINICAL INSTRUCTOR:
MS. EVELYN SANGUYU, RN
MEMBERS:
Gabriel, Nicole Pineda
Galang, Nicolette Joy Peco
Garcia, Janiel Jeann Capulong
Garcia, Zaymin Jell Gutierrez
Gilo, Vanezia Anne Galicia
Halili, John Paul Agustin
Laxina, Cyrus Gregory Gallano
Limin, Blessie Nucum
Manalili, Jovi Dela Cruz
Montoya, Lourdes Angel Santos
Moscoso, Charmaine Anne Elpedes
Ocampo, Sheeneid Aine Reclusado
ABSTRACT
A 24-year-old woman was admitted in labor. Initially, she
experienced acute pain related to the effects of labor and
delivery, as evidenced by the active phase of labor, with
uterine contractions that consistently increased in frequency
and intensity. The patient successfully delivered a baby boy,
maintained stable vital signs, experienced less distress, and
progressed through labor without major complications.
INTRODUCTION
The patient who was admitted in labor complained about
experiencing acute labor pain. Labor pain, as described by Hess et al.
(2020), is a multifaceted experience caused by uterine contractions
and pressure on the cervix. It can make the patient experience agony
through strong cramping and aching in the abdomen, back, and groin,
along with autonomic and emotional responses that vary in intensity
throughout the stages of labor.
INTRODUCTION
In this patient’s case, labor began spontaneously and proceeded normally
as foreseen. All factors that contributed to the patient’s pain were
addressed through various nursing interventions, to help ease the pain and
reduce the patient’s distress. During the procedure, the patient maintained
stable vital signs, experienced less distress, and progressed through the
entire procedure without complications, later delivering a healthy baby
boy.
This case emphasizes the importance of alleviating the client’s pain and
providing comfort through various nursing interventions during the
procedure, to ensure a healthy labor without experiencing threatening
complications.
HISTORY TAKING
Name Patient: X Gender: Female
Age: 24 years old Occupation: None
Civil status: Single Nationality: Filipino
Religion: Adventist Number of Admissions in
Place of birth: x the hospital: x
Present Residence: Date of Admission:
Pampanga November 12, 2024
HISTORY OF
PRESENT ILLNESS
OR INTERVAL
HISTORY
FHPTA (10am), patient had
onset of labor pains, crampy,
with progressive increasing
intensity and frequency no
vaginal discharge persistence
prompted to ER consent and
admitted.
ANALYSIS OF
Precipitating/Palliative Factors
Labor pain EACH
The patient was not in distress
SYMPTOMS
Quality
Minimal bleeding was observed, with no signs
of profuse bleeding
Pain in the lower abdomen caused by a
contracted uterus
No signs of difficulty of breathing (DOB) or
shortness of breath (SOB)
Patient had no complaints of headache,
nausea, and vomiting
ANALYSIS OF
Region/Location/Radiation
Pain was felt in the lower EACH
abdomen
SYMPTOMS
Severity/Intensity of Symptoms and its Progression
The patient experienced an onset of regular labor Timing
pains, with complaints of progressively increased The pain was periodic but its
in intensity and frequency
Patient reported minimal abdominal pain with a
severity level was just the same
pain scale of 1/10, pain remained unchanged Bleeding was minimal, with no
Bleeding was minimal and did not progress to
signs of periodic occurrence
profuse bleeding
CONSULTATION
Few hours prior to admission (10hrs.), the patient had onset of labor
pains, crumpy and progressive, increasing intensity and frequency.
No vaginal watery discharge
PAST MEDICAL HISTORY
Childhood diseases Hospitalizations or other illness not related
- No recorded childhood diseases - The patient has never been admitted to a
Immunization hospital for a condition unrelated to their
chief complaints
- No recorded immunization
Accidents/injuries
Blood transfusions
- No recorded past accidents or
- No recorded blood transfusions
injuries
Surgeries Psych
- Patient has no record of past - No recorded of psychiatric complications
surgeries from the patient such as drug overdose or
Allergies violence.
- Patient has no known food or drug
allergy
Family HISTORY 3rd generation
PERSONAL AND SOCIAL HISTORY
MENSTRUAL AND OB HISTORY
OB HISTORY
2 - Gravida - number of pregnancies
1 - Parity - number of outcomes
OB SCORE FPAL
1 - Full - Term
0 - Pre - Term (less than 28 weeks)
0 - Abortion (less than 20 weeks)
1 - Living
PHYSICAL ASSESMENT
PATOPHYSIOLOGY BOOK BASED
Patophysiology
(Normal Spontaneous
Delivery)
Non-Modifiable Modifiable
Age Sexual Intercourse
Sex
Meeting of sperm and egg cell
Fertilization
Murula
Blastocyst
Trophoblast
S/Sx Amenorrhea
Implantation of the
Increase levels of HCG
fertilized egg in the
and progesterone in
endometrial lining blood
Body reacts to increase
Attachment of the HCG 7 progesterone in
chorionic villi on the blood. Thus sending
maternal blood stream signals to the medulla
Stimulation of the
vagus nerve by the
Development of medulla
placental fragment
S/Sx Nausea and
Vomiting
Exchange of respiratory gases and waste and
nutrients via umbilical cord
1st Trimester 2nd Trimester 3rd Trimester
Organogenesis Organogenesis is Fetal position and
complete attitude is determined
Discernible heart beat
Sex is determined Increase abdominal size
(fetoscope)
due to growing
Presence of gestational Heartbeat is audible by
Slight abdominal
sac a simple stethoscope
contraction can be felt
PHYSICAL ASSESMENT
PATOPHYSIOLOGY PATIENT BASED
PHYSICAL ASSESMENT
ANATOMY AND PHYSIOLOGY OF THE FEMALE REPRODUCTIVE SYSTEM
EXTERNAL FEMALE REPRODUCTIVE SYSTEM
The female reproductive system includes several parts that work together
to aid in childbirth. It begins with the vulva, which is the exterior portion
that extends from the pubic region to the rectum. The vulva is made up of
the labia majora and minora, soft tissue folds that cover the vaginal and
urinary tract entrances. The clitoris is a tiny, sensitive organ that can
become erect when stimulated, whereas the hymen is a thin membrane that
partially covers the vaginal entrance (Nall, 2019)
PHYSICAL ASSESMENT
ANATOMY AND PHYSIOLOGY OF THE FEMALE REPRODUCTIVE SYSTEM
INTERNAL FEMALE REPRODUCTIVE SYSTEM
The vagina is a muscular tube that connects the exterior of the body to the
uterus. The vagina has two functions: it absorbs sperm during intercourse
and serves as the birth canal when a baby is born.
The cervix, or lower section of the uterus, is located at the end of the vagina.
The cervix permits sperm to enter the uterus while simultaneously keeping
hazardous pathogens away. It generates mucus that fluctuates during the
menstrual cycle, becoming thinner during ovulation to allow sperm to flow
more freely.
PHYSICAL ASSESMENT
ANATOMY AND PHYSIOLOGY OF THE FEMALE REPRODUCTIVE SYSTEM
The fallopian tubes are two thin tubes that link the ovaries and uterus. After
being released from the ovary, the egg travels through the fallopian tube. If
sperm is present and fertilizes the egg, the fertilized egg will go to the uterus
to implant and begin the pregnancy.
The ovaries produce egg cells. Every month, one egg develops and is
released through a process known as ovulation.
The ovaries also produce hormones that regulate the menstrual cycle and
prepare the body for pregnancy.
PHYSICAL ASSESMENT
ANATOMY AND PHYSIOLOGY OF THE FEMALE REPRODUCTIVE SYSTEM
The uterus, or womb, is a hollow organ where the fertilized egg grows into a
baby. The inner lining of the uterus, called the endometrium, thickens to
support the baby during pregnancy. The outer muscular layer, known as the
myometrium, helps push the baby out during childbirth. All these parts work
together to make it possible for women to conceive, carry, and give birth to
new life (West, 2021).
LABORATORY AND
DIAGNOSTIC PROCEDURES
LABORATORY AND
DIAGNOSTIC
PROCEDURES
LABORATORY AND
DIAGNOSTIC PROCEDURES
NURSING MANAGEMENT
NURSING MANAGEMENT
NURSING MANAGEMENT
FLUID MAINTENANCE
& RESUSCITATION
MEDICATION
SURGERY AND PROCEDURES
SURGERY AND PROCEDURES
SURGERY AND PROCEDURES
SURGERY AND PROCEDURES
COURSE IN WARD
COURSE IN WARD
COURSE IN WARD
DRUG STUDY
DRUG STUDY
DRUG STUDY
DRUG STUDY
NURSING CARE PLAN
PRE-OPERATIVE
NURSING CARE PLAN
POST-OPERATIVE
DISCHARGE PLAN
Thank you for
your attention
