Republic of the Philippines

Tarlac State University

College of Science
Department of Nursing
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Accredited Level 2 Status by the Accrediting Agency of Chartered Colleges and Universities in
the Philippines (AACUP), Inc.

A Clinical Case Study Presented to the

Faculty of the Department of Nursing, Tarlac State University

Villa Lucinda Campus,Brgy. Ungot, Tarlac City

Philippines

NURSING CARE MANAGEMENT 102

“NORMAL SPONTANEOUS DELIVERY”

Presented by:

Agustin, Anthony Elijah P.

Rojo, Vincent Luis M.

Arceo, Lei Ann Q.

Sugala, Rhajeeb Aennas A.

Gutierrez, Mark Neil C.

Matias, Jossa L.

Salunga, Merlene S.

Oladipupo, Emmanuel

Akintayo, Tomilola Blessing

Fasogba, Pelumi Morolake

Onu, Faith

Clinical Instructor
 TABLE OF CONTENTS

Introduction --------------------------------------------------------------------------- 1

Objectives of the study------------------------------------------------------------- 2

Nursing process Assessment --------------------------------------------------- 3

Personal data-------------------------------------------------------------------------- 3

Family history of health and illness------------------------------------------- 5

History of past illness--------------------------------------------------------------- 6

History of present illness---------------------------------------------------------- 6

13 Areas of Assessment ---------------------------------------------------------- 6

Laboratory and diagnostic procedure--------------------------------------- 11

Anatomy and Physiology-------------------------------------------------------- 12

Planning------------------------------------------------------------------------------- 14

Nursing Care Plan----------------------------------------------------------------- 14

Implementation--------------------------------------------------------------------- 17

Drugs----------------------------------------------------------------------------------- 17

Medical management------------------------------------------------------------- 23

Surgical management------------------------------------------------------------- 24

Conclusion----------------------------------------------------------------------------- 26

Recommendation-------------------------------------------------------------------- 27

Review of related literature/studies------------------------------------------- 27

Bibliography--------------------------------------------------------------------------- 28
I. INTRODUCTION

BRIEF DESCRIPTION OF THE CASE

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.

Premature rupture of membranes (PROM) refers to a patient who is beyond 37 weeks' gestation
and has presented with rupture of membranes (ROM) prior to the onset of labor. Preterm
premature rupture of membranes (PPROM) is ROM prior to 37 weeks' gestation. Spontaneous
preterm rupture of the membranes (SPROM) is ROM after or with the onset of labor occurring
prior to 37 weeks. Prolonged ROM is any ROM that persists for more than 24 hours and prior to
the onset of labor.

At term, programmed cell death and activation of catabolic enzymes, such as collagenase and
mechanical forces, result in ruptured membranes. Preterm PROM occurs probably due to the
same mechanisms and premature activation of these pathways. However, early PROM also
appears to be linked to underlying pathologic processes, most likely due to inflammation and/or
infection of the membranes. Clinical factors associated with preterm PROM include low
socioeconomic status, low body mass index, tobacco use, preterm labor history, urinary tract
infection, vaginal bleeding at any time in pregnancy, cerclage, and amniocentesis.

CURRENT TRENDS AND STATISTICS FOR

STAGES OF LABOR

1. First stage (Effacement and Dilatation)

Phases:

 Latent Phase: 0-4cm cervical dilatation

 Active phase: 4-7cm cervical dilatation
 Transitional Phase: 8-10cm cervical dilatation
2. Second Stage (Birth stage): from complete dilatation and effacement to the delivery of
the baby
3. Third Stage (Placenta stage): from the delivery of the baby to the delivery of the placenta
4. Fourth Stage (Recovery stage): the first hour after complete delivery

Mechanism of Labor

The ability of the fetus to successfully negotiate the pelvis during labor involves changes in
position of its head during its passage in labor. The mechanisms of labor, also known as the
cardinal movements, are described in relation to a vertex presentation, as is the case in 95% of
all pregnancies. Although labor and delivery occur in a continuous fashion, the cardinal
movements are described as 7 discrete sequences, as discussed below.

1. Engagement
The widest diameter of the presenting part (with a well-flexed head, where the largest
transverse diameter of the fetal occiput is the biparietal diameter) enters the maternal pelvis to a
level below the plane of the pelvic inlet. On the pelvic examination, the presenting part is at 0
station, or at the level of the maternal ischial spines.

2. Descent
The downward passage of the presenting part through the pelvis. This occurs intermittently with
contractions. The rate is greatest during the second stage of labor.

3. Flexion
As the fetal vertex descents, it encounters resistance from the bony pelvis or the soft tissues of
the pelvic floor, resulting in passive flexion of the fetal occiput. The chin is brought into contact
with the fetal thorax, and the presenting diameter changes from occipitofrontal (11.0 cm) to
suboccipitobregmatic (9.5 cm) for optimal passage through the pelvis.

4. Internal rotation
As the head descends, the presenting part, usually in the transverse position, is rotated about
45° to anteroposterior (AP) position under the symphysis. Internal rotation brings the AP
diameter of the head in line with the AP diameter of the pelvic outlet.

5. Extension
With further descent and full flexion of the head, the base of the occiput comes in contact with
the inferior margin of the pubic symphysis. Upward resistance from the pelvic floor and the
downward forces from the uterine contractions cause the occiput to extend and rotate around
the symphysis. This is followed by the delivery of the fetus' head.

6. Restitution and external rotation

When the fetus' head is free of resistance, it untwists about 45° left or right, returning to its
original anatomic position in relation to the body.

7. Expulsion
After the fetus' head is delivered, further descent brings the anterior shoulder to the level of the
pubic symphysis. The anterior shoulder is then rotated under the symphysis, followed by the
posterior shoulder and the rest of the fetus. (https://emedicine.medscape.com/article/260036-
overview#a2)

REASON FOR CHOOSING THE FOR PRESENTATION

The main reason why we choose this study is for the readers to have a broader
knowledge about normal spontaneous delivery. The researchers will also acquire knowledge
about how to give the best possible for the patient's condition. Mothers especially those who are
first-timers will also benefit from this by acquiring information with regards to the proper health
condition for her and her baby.

OBJECTIVES

1. General
During the course of the study, the student nurse, patient and significant others shall
have acquired knowledge of the course of the condition, its causes, signs and symptoms,
diagnosis and rendering effective nursing management

2. Specific Objectives: at the end of the rotation, our group will be able to:
1. Assess the health status of the patient
2. Plan and construct an effective nursing care to solve identified problems of the
patient
3. Implement the necessary nursing care in the care for the patient
4. Evaluate the effectiveness of nursing care rendered
3. Client centered
i. To determine the factors relevant to the client's present condition
ii. To develop Nursing care plan, establish rapport and to apply to the
patient
iii. To maintain client's well-being through different nursing interventions
appropriate for the condition.

I. NURSING PROCESS
A. ASSESMENT
1. PERSONAL DATA
a. Demographic Data
Name: Patient X
Age: 27 years old
Address: Del Pila East Zaragosa Nueva Ecija
Gender: Female
Date of birth: September 17, 1990
Nationality: Filipino
Religion: Catholic
Admitting Diagnosis: Premature Rupture of the membrane
Date admitted: January 24, 2018
Time admitted: 2:55:00 am
b. Environmental Status
Patient X is a 27-year-old who live in a rural area in Del Pila East Zargosa Nueva
Ecija. The house is consisting of 3 family members including her husband and
her child. They nuclear type of family. Their house is made of cement consisting
of 1 room and 1 window. Their source of water is faucet for drinking. They drink it
without boiling the water.
c. Lifestyle (habits, recreation, hobbies)
 Patient X eats her meal on time three times a day. She doesn’t like fatty and salty
foods. Everyday her fluid intake is 8 glasses of water. According to her she
doesn’t drink alcohol and she doesn’t smoke cigarettes. She usually spends her
time sleeping and going to school to fetch her child.

2. Family history of health and illness

GENOGRAM
Paternal Maternal

Grandmother Grandfather Grandmother Grandfather

-Father -Uncle -Aunt -Uncle -Uncle -Uncle -Aunt -Uncle -Patiemt -Aunt -Aunt -Uncle

-Female -Female (Diabetic) -Female (hypertension)

-Male -Male (Asthma) -Deceased Child

3. History of Past illness

Patient X stated that she had her complete check-up and vaccination. According to
her she had two pregnancy loss. She also had cough and fever and she had chicken
 fox when she was in grade 4. She doesn’t have any allergies to any foods, drinks,
animals and any medication. She was hospitalized before due to raspa.

4. History of present condition

Patient X was admitted at Tarlac Provincial Hospital last January 24, 2018 at 4:30
pm with complaint of
5. PHYSICAL ASSESSMENT (IPPA)

13 Areas of Assessment

I. SOCIAL STATUS

Patient X is a 27 years old female, residing in Del Pila East Zaragosa Nueva
Ecija. She was born on September 17, 1990 in Nueca Ecija. Because of her current
condition she look tired and weak, but she can still communicate with us and answer our
question without hesitating. She participated in our interview despite of the condition or
pain she felt. She usually spent her time going to school to bring her child to school
together with her friends. She was also happy with her husband and her family supports
her during her pregnancy.

NORMS:

Social status includes family relationship that states patient’s supportsystem in

time of stress and in time of need. It meets a fundamental human need for socialities
making life less stressful and social support buffers the negative effects of stress. Thus,
indicating indirectly contributing to good health outcomes. (Fundamentals of Nursing,
Barbara Kozier, Seventh edition)

Analysis/Interpretation:

Social status of patient X is normal because she has a good relationship with her
husband and with her family and friends. She can communicate well with them.

II. MENTAL STATUS

Patient X is a high school graduate and she was able to speak tagalog. The
arousability of the patient is fully awake and conscious. The patient is oriented in
time,place, and person during our interview and conversation with her. She was able
to answer all the questions we asked her without hesitations. She was able to read
and when we asked her what she feel she was able to answer about her condition.
We asked her when the date is she was admitted in the ward she can still remember
the date and how does she went to the hospital.

NORMS:
 The content of the patient message should make sense. The ability to read and
write should match the educational level. The patient should be able to correctly
respond to the questions and to identify all objects as requested. The patient should
be able to evaluate and act appropriately in situations requiring judgement. (health
assessment and physical examination 3th edition by Mary Ellen Zator Estes)
ANALYSIS:

The patients is normal state.

I. Emotional Status
Patient X is conscious and responsive as we asked her questions and
able to answer the questions properly without hesitations. Patient is
psychologically and emotionally prepared on her pregnancy. But you can still see
that she’s in pain during that state even though she’s answering the questions
with no hesitations.
Norms:
A human’s emotional status depends on his or her ability to cope up and be
ready for whatever can happen in their life. She or he may not be ready to be
emotionally stable of unfortunate happenings in life. (www.nursingceu.com)
Analysis:
The emotional status of the patient is normal.

I. Sensory Perception
Sense of sight
The eyes of the patient are equally round, and her pupils are dark brown, white
sclera and pinkish conjunctiva. Her eyebrows and eyelashes are equally
distributed. Patient’s eyes are reacting to light when we used the penlight in
assessing her. And she can also see the object clearly that is 20 feet away from
her according to her she can able to see clearly.

Norms:

The normal vision of an average person is 20/20 in distance of 20 feet

away and doesn’t wear any corrective graded lenses. (health assessment and
physical examination, Mary Ellen Zator Estes)

Analysis:

According to our assessment the patient’s vision is normal.

Sense of smell

The nose of the patient is symmetrical, has no lesion and she can also determine
the smell of the alcohol and the smell of the perfume we asked her to smell. She
doesn’t have a cold that obstruct her airway.
 Norms:

The person can smell and identify the aroma of a given object like perfume or
any other. The person should be able to distinguish the foul and good smelling.

Analysis:

The patient’s sense of smell is normal.

Sense of hearing

The ears of the patient are symmetrical and patent with each other, the color are
equal with the other parts of the body but there is a presence of earwax, no
discharged noted and no presence of lesions she can also hear the questions we
asked her and able to answer them properly we also do the whisper’s test we
whisper a word and she can able to repeat what we whisper to her.
Norms:
The auditory of the person is normal if the patient don’t have any tinnitinus or any
ear problem. He should be able to hear in the minimum of 2 feet away. (health
Assessment and physical examination, Mary Ellen Zator Estes)
Analysis:
The patient’s sense of hearing is normal.

Sense of taste

The patient’s tongue is pinkish no presence of lesions and any abnormalities

according to her she can taste the food and able to determine the taste of sugar and the
taste of a salt.

Norms:

A person usually identifies the taste of bitter, sweet and sour. By the use of our
sense of taste we can fix or adjust the taste of our cooked food based on our taste capacity.
(health assessment and physical examination, Mary Ellen Zator Estes)

Analysis:
Based on the assessment the sense of taste of the patient is normal.
Sense of touch (tactile sensitivity)
When we touched the patients skin she has a smooth and even skin color she can
also determine the part of the body where we touched her, and she also felt the pain
when we pinched her. She can also determine the wet and dry when we touch her
with wet and dry hands.
Norms:
The tactile sensitivity or hypersensitivity is an unusual or increased
sensitivity to touch that makes the person feel peculiar, noxious, or even in pain.
It is also called tactile defensiveness or tactile oversensitivity. Like other sensory
processing issues, tactile sensitivity can run from mild to severe.
 Analysis:
The sense of touch or the tactile sensitivity of the patient is normal.

II. Motor Stability

The patient can move her hands upward as we instructed her. Due to her current
state she can’t walk because she’s in labor and need assistance when she needs to
transfer from bed to table. But she grasps the hand of the interviewer she can also
do the dorsiflex.

Norms: Normal motor stability includes the ability perform different activities. It
should be firm and coordinated movements. (Estes, 2006)

Analysis:

The motor stability of the patient is not normal because she needs assistance when
turning to the side.

III. Body Temperature

The body temperature of the patient when we assess her is 39.0-degree celcius.

Norms:
Normal body temperature is within 36.4 C to 37.4 C. (Health assessment and
physical examination 3rd edition by Mary Ellen Zator Estes)
Analysis: Patient X temperature is above normal range

IV. Respiratory Status

The respiratory rate of the patient during the assessment is 16 cpm the depth of
respirations is effortless, but the pattern and rhythm are irregular.
Norms:
Normal respiratory rate for adult is 12-20 cpm, average is 18. In terms of pattern,
normal respirations must be regular and even in rhythm. The normal depth of
respirations in non-exaggerated and effortless (Health assessment and physical
examination 3rd edition by Mary Ellen Zator Estes)
Analysis:
The patient’s respiratory status is not normal.

V. Circulatory Status
The pulse rate of the patient is 90 bpm and the blood pressure that we get during the
assessment is 130/90.
Norms:
Normal cardiac rate for an adult is 60-100 beats per minute while the normal blood
pressure is 120/80 mmHg. The working capacity of the heart diminishes with aging.
The heart rate of older people is slow to respond to stress and slow to return to
normal after stress. Reduced arterial elasticity results in diminished blood supply to
 the parts of the body especially the extremities. (Health assessment and physical
examination 3rd edition by Mary Ellen Zator Estes)

Analysis:
The pulse rate of the patient is in normal range while the blood pressure is not in the
above normal range.

VI. Nutritional Status

According to the patient she eats 3x a day and she drinks 8 glasses of water every
day. She also eat fruits and vegetable and she doesn’t usually like fatty foods.
Norms:
Consider cultural and religious variations. Normal eating pattern is at on the
minimum of three times per day depending upon the metabolic demands and needs
of the patient. Fluid intake is on the average of 8-10 glasses per day (Monahan, 2002).
Analysis:
The patient’s nutritional status is normal.
VII. Elimination Status
Patient X usually defecates 2x a day with brown stool, and urinate 3 or 5 times a day
in a moderate amount.
Norms:
An individual usually defecate one to two times a day or every 2 day and urinates
30cc/hr. (Nutrition by Alex Abelos)
Analysis:
Elimination Status of patient X is normal.

VIII. Reproductive Status

Patient X had her first menstruation when she was 13 years old and her last
menstruation period is April 21 2017. She had her first sexual intercourse when she
was 15. She had two miscarriage and dilation and curitage.
Norms:
The first menstruation which is menarche occurs at an average of 9 to 17 years old.
(Maternal and Child Health Nursing 4th edition by Pilliterri)
Analysis:
Patient X menarche is normal because she had her menarche at 13 years old.
The reproductive status of the patient is not normal because she had experience
miscarriage and dilation and curitage.

IX. Sleep-rest Pattern

The patient usually sleeps at 9 pm and wake-up at 5am. She also nap in the
afternoon with her 1 year old child to have enough rest.
Norms:
Sleep refers to altered consciousness with general slowing of physiologic
process while rest refers to relaxation and calmness, both mental and physical.
 A person usually sleeps for about 7 to 9 hours a day and take a rest using some
of activities that will help you to relax including reading, watching television and
others.
Analysis:
Sleep-rest pattern of the patient is normal.

X. State of skin appendages

Skin of the patient is brown in color and appropriate to the whole body, she
has some presence of lesions on both legs. The hair is evenly distributed
black in color, The skin is warm to touch and no presence of edema, the nails
were untrimmed and dirty no presence of nail clubbing. Normal capillary refill
it returns after 3 seconds, there is presence of lenia nigra and stretch marks
in buttocks, hips, abdomen and on her waste and legs

Norms:
Obvious changes in the integumentary system (skin, hair, nails) with age. The
skin becomes drier and more fragile, the hair loses color, the finger nails and toe
nails become thickened and brittle, and i women over 60, facial hair increases.
These integumentary system changes accompany progressive losses of
subcutaneous fat and muscle tissues, muscle atrophy, and loss of elastic fibers.
(Fundamental of nursing 7th edition by Barbara kozier)

Analysis:
The patient’s skin is above normal because of multiple lesions present on her
legs.

LABORATORY AND DIAGNOSTIC PROCEDURES

Hematology

Test Result Analysis/Rationale

Hemoglobin 84 Normal The Patient’s

Hemoglobin is
Normal: 95 - 150 Normal

Hematocrit 0.314 Normal The Patient’s

Hematocrit is normal
Normal: 0.28 - 0.40

RH Type +

Platelet 22,000 Normal The Patient’s Platelet

is normal
 Normal: 150,00 –
450,000

Blood type B

RBC 3.86 Normal The Patient’s RBC is

Normal
Normal: 2.72 - 4.43

WBC 13.3 Normal The Patient’s WBC is

Normal
Normal: 5.6 - 16.9

MCV 80-96 fL) 81.3 Normal The Patient’s MCV is

normal

POLYS (0.55-0.63) 0.818 Not Normal Patients poly is

above normal Due to
55-63%
infection

MCH (27.5-32.2 pg) 29.0 Normal The Patient’s MCH is

normal

Serology

Hepatitis B Surface Non-Reactive

Antigen

Anatomy And physiology

ANATOMY AND PHYSIOLOGY OF LABOR

Birth (Parturition)

Onset of Labor

Prodromal labor, which includes the latent phase of labor, marks the initial stages of parturition.

Pre-labor (First Stage of Labor)

Pre-labor, also called prodromal labor, consists of the early contractions and labor signs before
actual labor starts. It is the body’s preparation for real labor.

Prodromal labor, often misnamed false labor, begins much as traditional labor but does not
progress to the birth of the baby. Not everyone feels this stage of labor although it does always
occur. However, this does not mean that every woman will experience every symptom.
The term is used to describe a cluster of physical changes that may take place in a pregnant
woman before she goes into actual labor. These changes can include:

 An increase in blood volume (sometimes resulting in edema).

 Braxton Hicks contractions.
 The presence of colostrum in the breasts.
 The dislodging of the mucous plug that sealed the cervix during the pregnancy.

The term false labor is sometimes used to describe a cluster of Braxton Hicks contractions that
are mistaken for real labor. The terms false labor and false pains are sometimes considered
equivalent.

Latent Phase

The latent phase is generally defined as beginning at the point at which the woman perceives
regular uterine contractions. In contrast, Braxton Hicks contractions should be infrequent,
irregular, and involve only mild cramping.

Cervical effacement (the thinning and stretching of the cervix and cervical dilation) occurs during
the closing weeks of pregnancy and is usually complete, or near complete, by the end of the
latent phase.

When the contractions of labor begin, the walls of the uterus start to contract through stimulation
by the release of the pituitary hormone oxytocin. The contractions cause the cervix to widen and
begin to open.

As labor progresses the amniotic sac can rupture and cause a slow or a fast gush of fluids.
Labor usually begins within a 24-hour period after the amniotic sac ruptures. As contractions
become closer and stronger the cervix will gradually start to dilate.

The degree of cervical effacement may be felt during a vaginal examination. A long cervix
implies that effacement has not yet occurred. At this stage, the cervix may dilate from 1 to 4 cm.
The latent phase ends with the onset of the active phase, which is marked by an accelerated
cervical dilation.

Stages of Labor

Vaginal delivery childbirth has three distinct phases: dilation of the cervix, delivery of the infant,
and delivery of the placenta.

The infant’s head and shoulders must go through a specific sequence of maneuvers in order to
pass through the ring of the mother’s pelvis. The six phases of a typical vertex (head-first
presentation) delivery are:

1. Engagement of the fetal head in the transverse position.

2. Descent and flexion of the fetal head.
 3. Internal rotation of the fetal head so that the baby’s face is towards the mother’s rectum.
4. Delivery by extension (the fetal head passes out of the birth canal).
5. Restitution: The fetal head turns through 45 degrees to restore its normal relationship
with the shoulders, which are still at an angle.
6. External rotation: The shoulders repeat the corkscrew movements of the head, which
can be seen in the final movements of the fetal head.

The Bishop score defines several factors that midwives and physicians use to assess the
laboring mother’s progress.
The score is used to predict whether the mother is likely to spontaneously progress into the
second stage of labor and whether induction of labor will be required. It has also been used to
assess the odds of spontaneous preterm delivery.

Stages of Labor

First Stage (Active Phase)

The first stage of labor classically starts when the effaced (thinned) cervix is 3 cm dilated,
although there is variation as some women may or may not have active contractions prior to
reaching this point. The onset of actual labor is defined when the cervix begins to progressively
dilate. Rupture of the membranes or a bloody discharge may or may not occur at or around this
stage.

Tterine muscles form opposing spirals from the top of the upper segment of the uterus to its
junction with the lower segment. During effacement, the cervix becomes incorporated into the
lower segment of the uterus. During a contraction, these muscles shorten the upper segment,
drawing upwards the lower segment in a gradual expulsive motion.

The presenting fetal part is then permitted to descend. Full dilation is reached when the cervix
has widened enough to allow passage of the baby’s head, around 10 cm dilation for a term
baby. The duration of labor varies widely, but the active phase averages some 20 hours for
women giving birth to their first child (primiparae), and 8 hours for women who have already
given birth (multiparae).

Active phase arrest is defined, in a primigravid woman, as the failure of the cervix to dilate at a
rate of 1.2 cm/hr over a period of at least two hours. This definition is based on Friedman’s
Curve, which plots the typical rate of cervical dilation and fetal descent during active labor.
Some practitioners may diagnose failure to progress, and consequently, perform a caesarean.
 Second Stage (Fetal
Expulsion)

The second stage begins when the

cervix is fully dilated and ends when the
baby is born. As pressure on the cervix
increases, the Ferguson reflex
increases uterine contractions.

At the beginning of the normal second

stage, the head is fully engaged in the
pelvis: the widest diameter of the head
has passed below the level of the pelvic
inlet. The fetal head then continues
descending into the pelvis, below the
pubic arch, and out through the vagina.

This is assisted by the additional

maternal efforts of bearing down or
pushing. The fetal head is seen to
crown as the labia part. At this point, the
woman may feel a burning or stinging
sensation. The complete expulsion of
the baby signals the successful
completion of the second stage of labor.

The second stage of birth will vary by

factors including parity, fetal size,
anesthesia, or the presence of infection.
Longer labors are associated with
declining rates of spontaneous vaginal
delivery and increasing rates of
infection, perineal laceration, obstetric
hemorrhage, as well as need for
intensive care of the neonate.

Third Stage (Placental

Delivery)

The third stage of labor is the period from just after the fetus is expelled until just after the
placenta is expelled. The average time from delivery of the baby until complete expulsion of the
placenta is estimated to be 10–12 minutes.

Placental expulsion can be managed actively, by giving a uterotonic, such as oxytocin, along
with appropriate cord traction and fundal massage to assist in delivering the placenta by a
skilled birth attendant. Alternatively, it can be managed expectantly, allowing the placenta to be
expelled without medical assistance. The umbilical cord is routinely clamped and cut in this
stage, but it would normally close naturally even if not clamped and cut.
When the amniotic sac has not ruptured during labour or pushing, the infant can be born with
the membranes intact. This is referred to as being born in the caul. The caul is harmless, and its
membranes are easily broken and wiped away. With the advent of modern interventive
obstetrics, the artificial rupture of the membranes has become common, so babies are rarely
born in the caul (en-caul birth).

Fourth Stage (Postpartum Period)

The fourth stage of labor is a term used in two different senses:

1. It can refer to the immediate puerperium, or the hours immediately after delivery of the
placenta.
2. It can be used in a more metaphorical sense to describe the weeks following delivery.

Adjustments of the Infant at Birth

Post birth, an infant’s physiology must adapt to breathing independently, changes in blood flow
and energy access, and a cold environment

The first challenge of a newborn is to perfuse its body by breathing independently instead of
utilizing placental oxygen. At birth, the baby’s lungs are filled with fetal lung fluid (which is not
amniotic fluid) and are not inflated.

As the newborn is expelled from the birth canal, its central nervous system reacts to the sudden
change in temperature and environment. This triggers it to take the first breath within about 10
seconds of delivery.

With the first breaths, there is a fall in pulmonary vascular resistance and an increase in the
surface area available for gas exchange. Over the next 30 seconds, the pulmonary blood flow
increases and is oxygenated as it flows through the alveoli of the lungs. Oxygenated blood now
reaches the left atrium and ventricle and, through the descending aorta, reaches the umbilical
arteries.

Respiration and Circulation

Oxygenated blood now stimulates constriction of the umbilical arteries resulting in a reduction in
placental blood flow. As the pulmonary circulation increases, there is an equivalent reduction in
the placental blood flow that normally ceases completely after about three minutes. These two
changes result in a rapid redirection of blood flow into the pulmonary vascular bed, from
approximately 4% to 100% of cardiac output.

The increase in pulmonary venous return results in left atrial pressure being slightly higher than
right atrial pressure, which closes the foramen ovale. This change in the pattern of flow results
in a drop-in blood flow across the ductus arteriosus.
The higher blood oxygen content of blood within the aorta stimulates the constriction and
ultimately the closure of this fetal circulatory shunt. All of these cardiovascular system changes
result in the adaptation from fetal circulation patterns to an adult circulation pattern.

During this transition, some types of congenital heart diseases that were not symptomatic in
utero during fetal circulation will present with cyanosis or respiratory signs.

Following birth, the expression and re-uptake of surfactant, which begins production at 20
weeks gestation, is accelerated. Expression of surfactant into the alveoli is necessary to prevent
alveolar closure.

At this point, rhythmic breathing movements also commence. If there are any problems with
breathing, management can include stimulation, bag and mask ventilation, intubation, and
ventilation. Cardiorespiratory monitoring is essential to track potential problems.

Pharmacological therapy, such as caffeine, can also be given to treat apnea in premature
newborns. A positive airway pressure should be maintained, and neonatal sepsis must be ruled
out. Potential neonatal respiratory problems include apnea, transient tachypnea of the newborn
(TTNB), respiratory distress syndrome (RDS), meconium aspiration syndrome (MAS), airway
obstruction, and pneumonia.

PATHOPHYSIOLOGY ON PREMATURE RAPTURE OF MEMBRANES

Rapture of membranes before onset of labor is considered premature. Diagnosis is clinical.

Delivery is recommended when gestational age is ≥34 wk and is generally indicated for infection
or fetal compromise regardless of gestational age.

Premature rupture of membranes (PROM) may occur at term (≥37 wk) or earlier (called preterm
PROM if < 37 wk).

Preterm PROM predisposes to preterm delivery.

PROM at any time increases risk of infection in the woman (chorioamnionitis), neonate (sepsis),
or both, as well as risk of abnormal fetal presentation and abruptio placentae. Group B
streptococci and Escherichia coli are common causes of infection. Other organisms in the
vagina may also cause infection.

PROM can increase risk of intraventricular hemorrhage in neonates; intraventricular

hemorrhage may result in neurodevelopmental disability (eg, cerebral palsy).

Prolonged preterm PROM before viability (at < 24 wk) increases risk of limb deformities (eg,
abnormal joint positioning) and pulmonary hypoplasia due to leakage of amniotic fluid (called
Potter sequence or syndrome).

The interval between PROM and onset of spontaneous labor (latent period) and delivery varies
inversely with gestational age. At term, > 90% of women with PROM begin labor within 24 h; at
32 to 34 wk, mean latency period is about 4 days.
 B. Planning
NCP: Pain Related to labor contractions

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
Subjective: Pain Within 4 Encourage An upright, After 4 hours,
Related to hours comfortable sitting, or client states
“Masakit po labor reduce the postioning. walking pain is
talaga.” As contractions pain level position may reduced to a
verbalized by during the be most tolerable level
the patient. labor comfortable with
progression for a woman.
techniques
Contractions
used and is
Objective: are more
efficient in able to handle
this position. “work with”
Facial Grimace contractions;
demonstrates
Uncomfortable
ability to listen
Irritability and respond
to questions
restlesness and
instruction.

Depending
Assist the on the type
of childbirth
Vital Signs: woman with
preparation
the prepared
BP= 130/90 a woman
childbirth
and her
method support
Pain Scale:
9/10 person have
had, the
method used
may include
T: 39.0°C breathing
exercises,
PR: 90 bpm distraction
by focusing
RR: 16 cpm on an
external
object,
acupressure,
therapeutic
 touch, music
theraphy,
guided
imaginary,
self-
hypnosis, or
combination
of this
methods.

Provide
Pharmacologic Medication
pain relief effectively
used during
labor must
relax a
woman and
relieve his
discomfort,
yet have
minimal
systemic
effects of
uterine
contraction

NCP: Anxiety related to lack of knowledge about labor experience

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
Subjective: Anxiety Acquires Reduce A woman After 2-3 hours
related to lack knowledge anxiety with having first client identifies
??? of knowledge about explanation child beginning and
about labor childbirth of the labor probably ending of
. experience and is process does not contractions;
better cope know these expresses
with future things. A
confidence
Objective: births woman
rather than
having a
second confusion about
Facial child may ongoing
Grimace not process
remember,
Uncomfortable
or she may
Irritability find this
time so
 restlesness different
from the
last time
she is
frightened.
Vital Signs:

BP= 130/90

T: 39.0°C

PR: 90 bpm

RR: 16 cpm

NCP: Risk for Infection related to Premature Rupture of Membranes

Assessment Nursing Plannin Intervention Rationale Evaluation

Diagnosis g
Subjective: Risk for After 2-3 Perform initial - Repeated After 2-3
Infection hours vaginal examination, vaginal hours
Nurse pumutok related to maternal when the contraction examinations Mother
na po Premature infection pattern repeat, or play a role in states /
patubigan ko Rupture of does not maternal behavior the incidence shows are
Membranes occur of ascending free of any
Objective: indicates progress. tract infections.
signs of
infection.
Facial Grimace
Within 4 hours
Uncomfortable after
membrane
Irritability rupture,
chorioamnioniti
restlesness s incidence
Monitor temperature, increased
pulse, respiration, progressively
and white blood cells in accordance
with the time
as indicated.
indicated by
Vital Signs:
vital signs.
BP= 130/90
 Antibiotic may
protect against
T: 39.0°C the
development
PR: 90 bpm of
chorioamnioniti
RR: 16 cpm s in women at
risk.
Give prophylactic
antibiotics when
indicated.

NCP: Anxiety related to lack of knowledge about labor experience

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
Subjective: Anxiety Acquires Reduce anxiety A woman After 2-3
related to knowledge with explanation of having first hours client
“Medyo lack of about the labor process child probably identifies
kinakabahan knowledge childbirth does not know beginning
ako..” As about labor and is these things. A and ending
verbalized by experience better woman having of
the patient. cope with a second child
contractions;
future may not
expresses
births remember, or
Objective: she may find confidence
this time so rather than
different from confusion
Facial the last time about
Grimace she is ongoing
frightened. process
Uncomfortable

Irritability

restlesness

Vital Signs:

BP= 130/90
 T: 39.0°C

PR: 90 bpm

RR: 16 cpm

C. IMPLEMENTATION
DRUGS
Name of Date Route of General Indication Client’s Nursing responsibilities prior to,
drugs admini administ action Purpose response to during and after the procedure
(generic stered ration Mechanism of med. With
and dosage action actual side
brand and effects (if any)
name) frequen
cy of
administ
ration
 01/30/1 10 IU IV Oxytocin is1. Common side Start flow chart to record maternal BP
OXYTOCIN Oxytocin works and other VS, I&O ratio, weight,
8 a natural effects of
(Pitocin) by increasing the PITOCIN strength, duration, and frequency of
hormone
concentration of contractions as well as the FHT and
that causes 2. – redness or
calcium inside rate, before instituting treatment.
the uterus irritation at the
muscle cells that injection site
to contract.
control
Oxytocin is3. -loss of appetite Monitor FHR and Maternal BP and
contractions of
used to 4. -nausea Pulse at least q15 during infusion
the uterus. period; evaluate tonus of myometrium
induce 5. -vomiting
Synthetic water- during and between contractions and
labor or 6. -cramping
soluble record on flow chart. Report change in
strengthen7. -stomach pain
polypeptide rate and rhythm immediately.
labor 8. -more intense or
consisting of
contraction more frequent
eight amino
during contractions Stop infusion to prevent fetal anoxia,
acids, identical turn patient on her side, notify
childbirth, 9. -runny nose
pharmacological physician if contractions are prolonged
and to -sinus pain or
ly to the oxytocic (occurring at less than2 mins interval)
control irritation
principles of the and if monitor records contractions
bleeding -memory problem
posterior about 50 mmHg or if contractions last
after 90 seconds longer. Stimulation will
pituitary
childbirth. wane rapidly within 2-3 mins. Oxygen
Oxytocin is administration may be necessary.
also used
to stimulate
uterine If local or regional (caudal, spinal)
anesthesia is being given to the
contraction
patrient receiving oxytocin, be alert to
s in a the possibility of hypersensitivity crisis
woman with (sudden intense occipital headache,
incomplete palpitation,marked
or hypertension,stiffneck,nausea,vomiting
threatened ,sweating,fever,photophobia dilated
pupils bradycardia or tachycardia,
miscarriage
constricting chest pain)

Monitor I&O during labor. If patient is

receiving drug by prolonged IV
infusion, watch for symptoms of water
intoxication (drowsiness, listlessness,
headache, confusion, anuria, weight
gain). Report changes in alertness and
orientation and changes in I&O ration.
Check fundus frequently during the
first postpartum hours and several
times daily thereafter.

Incidence of hypersensitivity or allergic

reactions is higher when oxytocin is
given by IM or IV injection rather than
by IV infusion
 01/30/18 1 amp IV 10. Constipation Patient & Family Education
HNBB Buscopan blocks hyoscine
(buscopan) the muscarinic butylbromide 11. Decreased
1. Take this drug 30 minutes to
sweating
receptors found also known as 1 hour before meals
on the smooth scopolamine 12. Mouth, skin, eye
2. Buscopan will potentiate the
dryness
muscle walls butylbromide effect of alcohol and other
13. Blurred feeling CNS depressants.
which means its and sold under
blocks the action the brandname 14. Bloating 3. Do not take antacids and
of acetylcholine buscopan is 15.
a Dysuria antidiarrheal 2 to 3 hours prior
16. Nausea or to raking this drug.
on the receptors medication used
found within the to treat crampy vomiting 4. It is not necessary to take the
17. Lightheadedness medication if you are not in
smooth muscle of abdominal pain,
pain.
the esophageal 18. Headache
5. Avoid driving or operating
gastrointestinal spasms, renal 19. Weakness
machinery after parenteral
and urinary tract coli, and bladder dose.
infection and thus spasms.
reduces the
spasms and
contraction
 1-gram -cefazolin inhibits -susceptible -determine hypersensitivity to
Cefazolin 01/30/18 GI upset,
IV ANST cell wall bacterial cephalosporins, penicillins
(Cephalosporin) anaphylaxis, rash,
biosynthesis by infections and other drugs, before
pruritus, local
binding Pinicilin including therapy is initiated.
reactions, blood
binding proteins septicemia,
dyscrasias,
which stops respiratory, -lab test: perform culture and
elevated liver
peptidoglycan biliary or GU sensitivity testing prior to and
enzymes.
synthesis. trac, skin and during therapy. Therapy may
Pinicilin binding skin structure, be initiated pending result.
proteins are bone and joint
bacterial proteins endocarditi. - monitor I & O rates and
that help to Surgical pattern: be alert to changes in
catalyze the last prophylaxis. BUN serum creatinine.
stages of
peptiglycan - If Patient has had a reaction
synthesis which is to penicillin, be alert to signs
needed to of hypersensitivity with the
maintain the cell use of cefazolin. Cross-
wall. They allergenicity between
remove the D- cephalosporin and penicillin
alanine from has been reported. Prompt
precursor of the attention should be given to
peptidoglycan. onset of signs of
The lack of hypersensitivity.
synthesis causes
the bacteria to - promptly report the onset of
lyse because they diarrhea which may of may
also continually not be dose related. It is seen
breakdown their especially in patients with
cell walls. history drug-related GI
Cefazolin is disturbances.
bactericidal, Pseudomembranous colitis, a
meaning it kills potentially life-threatening
the bacteria condition, starts with diarrhea.
rather than
inhibiting their
growth.

Medical Management
Medical management/ Date General Indication/ Client’s reaction to
Treatment Performed/ description purpose treatment
Changed/
Discontinued

Intravenous Fluids 01/30/18 D5LRS 1L 10-15 -Use to treat - Frequent voiding

gtts/min dehydration. It is use
to maintain know the type, amount and
homeostasis when indication of IV therapy
To deliver liquid enteral intake is
insufficient. - practice strict asepsis
substances
directly into the -corrects electrolyte -inform client and explain
vein. imbalances. Deliver purpose of therapy
medication and
blood transfusion -Prime IV tubing to expel air.
This will prevent air embolism

-Clean the insertion area of

hairy.
-Change IV tubing every 72 hrs
to prevent contamination
-Change/ alter needle insertion
site every 72 hrs to prevent
thrombophlebitis
Regulate IV every 15-20 mins
to ensure administration of
proper volume of IV

SURGICAL MANAGEMENT
Name of Date Brief Indication/ Client’s Nursing responsibilities prior to
Procedure Performed description purpose response to during and actual surgical
operation procedure
This Several side
Episiotomy 12/02/117 A surgical procedure effects of - position the mother in lithotomy.
cut made at is usually episiotomy
the opening -clean vaginal bleeding
done have been
of the during the reported, -Provide reassurance to the patient
vagina delivery or including during the procedure.
during birthing infection,
childbirth, to -clean the perineal area with
process increased pain
aid a difficult betadine solution
when the prolonged
delivery and vaginal healing time -apply sterile pads and tie
prevent opening and increased
rupture of does not discomfort once -make the patient lie comfortably
tissue stretch sexual back in supine position
enough to intercourse is
-clean and dry the patient
allow the resumed. There
thoroughly
baby to be is also the risk
delivered that the - change into fresh clothing
without episiotomy
tearing the incision will be -document
surrounding deeper or loner
tissue. than is
necessary to
permit the birth
of infant. There
is a risk of
increased
bleeding

DIET
Type of Diet Date Indication/s Nursing Responsibility

SOFT DIET 01/30/18 To prevent constipation. Explain to the patient the importance of
taking soft diet Instruct the patient to
take soft diet after
to help normalize intestinal
motility
Increase fluid 01/30/18 To rehydrate Instruct the patient to increase fluid
intake
To help normal digestion
Foods high in fiber 01/30/18 For normal digestion Encourage the patient to take foods
rich in fiber such as fruits and
To help normalize bowel vegetables
movement

FOOD HIGH In 01/30/18 Folic acid is effective in the Encourage the patient to take foods
FOLATE treatment rich in folate such as fruits and
of megaloblastic anemias due vegetables
to a deficiency of folic acid as
may be seen in tropical or non-
tropical sprue, in anemias of
nutritional origin, pregnancy,
infancy, or childhood.

CONCLUSION
At the end of the exposure in the LR/DR. After few days of gathering data on our
proposed case study about post-partum of normal spontaneous delivery, we, student nurses of
Tarlac State University gained a lot of knowledge, enhanced our skills and improve our attitude
during the exposure inside the LR/DR. At first, we felt nervous and excited as well but the next
exposure, we could conquer our fears and do the appropriate nursing procedures or
interventions and build a good trust and rapport with our own patient. We encountered different
patient and different attitudes during the exposure, but we never forget to stay humble, kind and
still provide the right interventions that they needed. Duty in the LR/DR thought us on how to
handle a labouring and delivering mother. During the exposure, also, we performed cord care to
newborn and demonstrated it to their mothers and rendered a health teaching as well. Key skills
we have embedded into our case studies include Group working, individual study skills,
information gathering and analysis, Time managements, presentation skills and last are the
practical skills.

Based on the complied in this case study, we therefore conclude that all the
objectives and goals that we made were met. Our client complied and understood everything we
have informed her. We, student nurses gain more knowledge, improve our skills, improve our
attitude. Now, that we’ve been exposed in the area. We now have the knowledge so that we can
prepare ourselves in the future

IV. RECOMMENDATION

A. Student Nurse

To our fellow student nurses, to improve our knowledge and abilities in rendering
proper and effective nursing care. Making a case study is important; it is an
 indispensable tool that will help develop knowledge and skills competency in
understanding specific cases. It is not only about establishing good nurse-patient
relationship, but also having the chance to work with our fellow student. In making a
case study you need to render time, effort and sacrifice for achieving the goal of
finishing the case study. Being willing to learn and work on making a case study can
enhance our knowledge and mind that will lead us to achieving our goal for our patient
and also for ourselves.

B. Patient

For the patient, she must increase fluid intake to make up with the ones she lost during
delivery. Eating of nutritious foods like fruits and vegetables and having a well-
balanced diet is necessary. The patient must also take minerals that are rich in Iron
and Vitamin A. Post-natal visits is required to determine what is the state of wellness
after her confinement. The patient must also perform and know the benefits of
breastfeeding for her and the baby.

C. Health Provider

For the health care provider, they should understand the condition of the patient.
Understanding different post-partum cases is very important to help the health care
provider to perform their duty properly and in providing proper effective nursing care.

REVIEW OF RELATED LITERATURE/STUDIES

Premature rupture of membranes (PROM) refers to a patient who is beyond 37 weeks' gestation
and has presented with rupture of membranes (ROM) prior to the onset of labor. Preterm
premature rupture of membranes (PPROM) is ROM prior to 37 weeks' gestation. Spontaneous
preterm rupture of the membranes (SPROM) is ROM after or with the onset of labor occurring
prior to 37 weeks. Prolonged ROM is any ROM that persists for more than 24 hours and prior to
the onset of labor.

At term, programmed cell death and activation of catabolic enzymes, such as collagenase and
mechanical forces, result in ruptured membranes. Preterm PROM occurs probably due to the
same mechanisms and premature activation of these pathways. However, early PROM also
appears to be linked to underlying pathologic processes, most likely due to inflammation and/or
infection of the membranes. Clinical factors associated with preterm PROM include low
socioeconomic status, low body mass index, tobacco use, preterm labor history, urinary tract
infection, vaginal bleeding at any time in pregnancy, cerclage, and amniocentesis.

Premature Rupture of Membranes (at Term)

Premature rupture of membranes (PROM) at term is rupture of membranes prior to the onset of
labor at or beyond 37 weeks' gestation. PROM occurs in approximately 10% of pregnancies.
Patients with PROM present with leakage of fluid, vaginal discharge, vaginal bleeding, and
pelvic pressure, but they are not having contractions.

Premature preterm rupture of membranes (PPROM) occurring from 24-37 weeks' gestation is far
more difficult to manage than premature rupture of membranes (PROM) at term. Several issues
need to be considered in formulating a plan of management. Prematurity is the principal risk to
the fetus, while infection morbidity and its complications are the primary maternal risks. All
plans for management of PPROM remote from term should include the family and the medical
team caring for the pregnancy, including the neonatal and maternal medical team. Remote from
term, PPROM should only be cared for in facilities where a NICU is available and capable of
caring for the neonate. Because most PPROM pregnancies deliver within a week of ROM,
transfer of the pregnant mother to a qualified facility is urgent and should be facilitated
immediately upon diagnoses.

The vast majority of women proceed to active labor and deliver soon after PPROM. With
appropriate therapy and conservative management, approximately 50% of all remaining
pregnancies deliver each subsequent week after PPROM. Thus, very few women remain
pregnant more than 3-4 weeks after PPROM. This is important information to give the woman
considering expectant management remote from viability.

VI. BIBLIOGRAPHY

A. Websites

http://www.healthline.com/health/postpartum-care#AfterDelivery2
https://en.wikipedia.org/wiki/Pregnancy
https://en.wikipedia.org/wiki/Pregnancy
http://www.livestrong.com/article/144952-about-normal-spontaneous-vaginal-delivery/
http://www.aafp.org/afp/2008/0801/p336.html
https://www.google.com.ph/search?q=PREGNANCY+RATES+FOR+ADOLESCENT&dcr=0&so
urce=lnms&tbm=isch&sa=X&ved=0ahUKEwiD2bGc4dTWAhWDw7wKHUE_BjkQ_AUICigB&bi
w=1350&bih=615#imgrc=Hm2OPm9zDhjwOM:
https://www.google.com.ph/search?q=review+of+related+literature+about+normal+spontaneous
+delivery&dcr=0&ei=_b_TWbmHLIn98gWZm77gDg&start=10&sa=N&biw=1350&bih=615
https://emedicine.medscape.com/article/261137-overview#a3