Daniela M.

Diana
BSN II

NORMAL SPONTANEOUS DELIVERY

I. INTRODUCTION
A. Normal Spontaneous Delivery

II. BIOGRAPHIC DATA

Name: Patient X
Age: 29 years old
Status: Single
Date of Birth: February 14, 1990
Place of Birth: Calauan Laguna Case Number: 188752
Address: Dayap Calauan
Educational Attainment: Elementary
Religion: Roman Catholic
Case Number: 188752
Date Admitted: October 13, 2019 at 3:24 AM
Chief complaint: Uterine Contraction
Admission Diagnosis: G5P4
Final Diagnosis: G5P5 (5005) PU vertex delivered spontaneously to an alive baby boy.
Date &Time of Delivery: October 13, 2019 at 9:50 AM
Oxytoxin Administered: 9:51AM
Placenta Out: 9:55 AM
Blood Pressure: 110/80
Principal Operation/Procedure: Perineal Support
LMP: January 5, 2019
 EDC: October 12, 2019
AOG: 40 1/2
FH: 28
FHT: 141

II. ASSESSMENT

A. Social Status

Patient X is a 29 years old, born on February 14, 1990 at Calauan Laguna. She resides at
Dayap Calauan together with her live-in partner and her children in her 1st partner. They were
living together for 5 years. According to Patient X they are not yet married because they don’t
have enough money to get married but in a future they want to get married. Patient X has 2
children in her 2nd partner including the new born baby. Patient X is also not married to her 1st
partner but they have 3 children. Mr. Y is working as a construction worker at Pasig. Their
savings supported the hospitalization of Patient X. She has no work, she stays at home taking care
of her children.

B. Lifestyle

Patient X described her habits by doing household chores during her pregnancy. But when the 7th
month of her pregnancy came, she limits her activities in their house. She eats normally ( 3 times
a day ) including a diet that contains vegetables, rice and bread. During her pregnancy she always
eat fruits. She is always drinking Kalamansi Juice because according to her belief it is best
Vitamin C. Patient X has no history of drinking alcohol beverages and smoking. She

C. History of Preset Illness

Few hours prior to admission, Patient X experienced uterine contraction. She has a good fetal
movement and she has no watery vaginal discharge. She was admitted with a chief complaint of
uterine contraction and she delivered an alive baby boy via normal spontaneous delivery. She
did not undergo episiotomy but they performed perineal support. After the post natal and early

D. Past Medical History and Illness

Patient X has no allergy in any medication and food. She has no past illness like asthma,
hypertension and diabetes. But she experienced cold, cough and fever before. They never
experienced to be confined in the hospital. They were just going to the center to have her prenatal
check up or if she is not feeling well. She also verbalized that she experience chickenpox and sore
eyes during her childhood.

E. Family History
Patient X family has no history of having hypertension, asthma and diabetes and in any
diseases. They are just experiencing cough, cold and fever.
F. Elimination

Patient X defecated once during the delivery. She voided five times and defecated once after
delivery. She had a past no history of Urinary Tract Infection(UTI).

G. Reproductive Status

Some of her reproductive organ is altered especially the external areas but it is considered normal
due to the process of delivery. Her menstrual period was regular.
Analysis:
Patient X marked the physiologic changes of pregnancy hence, reproductive status is altered but q
expected to return to normal status after 1 month (approximately)

H. State of Physical Rest and Comfort

Patient X sleeping pattern is not good because usually she sleep at 12: 00 am and wake up at 9-
10 am because she is experiencing any discomfort because of the abdominal pain but her
husband is always there to support her.

I. State of Skin Appendages

I noticed that Patient X lip and eyes appears pale. There is also presence of scars on her upper
and lower extremities. The hair distribution is normal. Her skin also appears dry and her original
skin color is brown. Patient X has a edema in her lower extremities when I press to measure
the depth of the indention. Her skin rebound immediately and the its scale is 1+ which means
there is barely detectable 2 mm depression.

J. Vital Signs

BODY TEMPERATURE
The table below shows the body temperature of Patient X

DATE TIME TEMPERATURE ANALYSIS

10/13/19 - 36.5ᵒ C Normal

10/15/19 7:00 36.9ᵒ C Normal

AM
12:00 37.5ᵒ C Normal
PM
 RESPIRATORY STATUS
The table below shows the respiratory rate of Patient X

DATE TIME RESPIRATORY ANALYSIS

RATE
10/15/19 7:00 18 Normal
AM
12:00 18 Normal
PM

CIRCULATORY STATUS
The circulatory status of Patient X as well as the blood pressure noted below

DATE TIME PULSE BLOOD ANALYSIS

RATE PRESSURE
1O/13/19 - - 110/80 Normal
10/14/15 - - 110/80 Normal
10/15/19 7:00 AM 84 110/70 Normal
12:00PM 80 110/70 Normal

III. DIAGNOSTIC AND LABORATORY

Complete Blood Count (CBC) Result Form

October 13, 2109

PARAMETER RESULT UNIT REF. RANGE

RBC 3.69 10^12/L 3.50 – 5.00
HGB 92 g/L 110 – 150
HCT 27.8 L % 37.0 – 47.0
MCH 23.8 L Pg 27.0 – 34.0
MCHC 317 L g/L 320 - 360
MCV 75.4 L Fl 80.0 – 100.0
RDW-CV 18.1 H % 11.0 – 16.0
WBC 12.56 H 10^9/L 4.00 – 10.00
WBC
 Differential (%)
Lymphocyte 20.1 L % 20.0 – 40.0
Neutrophil 71.5 H % 50.0 – 70.0
Eosinophil 1.6 % 3.0 – 12.0
Monocyte 6.7 L % 0.5 – 5.0
Basophil 0.1 % 0.0 -1.0
PLT 376 H 10^9/L 100 – 300
MPV 7.9 fL 6.5 – 12.0
PDW 16.2 9.0 – 17.0

Hematology
Method: EKF (POCT) BC5800

Test Result Normal Values

Hemoglobin (Hb) 8.7 F: 12-14 g/dL
M:14-16 g/dL
Child: 10-13 g/dL
NB: 13-14 g/dL
Hematocrit (Hct) 26 F: 35-45 %
M: 41-64 %
Child: 33-40 %
NB: 42-59 %
Platelet Count - 150-500 X 1O 9/ L

Hepatitis B Virus Screen Test

October 13,2019
Method: Rapid Diagnostic Kit

Result: Hepatitis B Surface Antigen (HBsAg) = NON-REACTIVE

 Blood Typing – ABO, Rh (D)
October 13, 2019
Method
 Slide
Tube
Gel Card
Result:
Blood Type: AB
Rh: Positive (+)

Date: August 16, 2019
LMP: January 5, 2019
Obstetrical Ultrasound
nd rd
Report ( 2 and 3 Trimester)
EDD: October 12, 2019
AOG: 31 Weeks

BPD 8.34cm 33w4d

General Survey
OFD 10.24cm 31w6d
No. of Fetuses: Singleton HC 29.34cm 32 w3d
AC 25.55 cm 29 w5d
Presentation: Cephalic
FL 5.77 cm 30 w1d
Amniotic Fluid: 12.86 cm
Ave. Ultrasound Age: 31wks & 2 days
Placenta
Ultrasound EDD: October 16, 2019
Location: Posterior
EFW: 1569 grams ( 31 lbs 7oz)
Grade : II
FHT: 143 bpm
Cerebrum: 3.67 cm= 30w2d

Impression:
Pregnancy Uterine 31 weeks and 2 days by fetal biometry
Cephalic, live singleton fetus
EFW 1569 grams ( 31 lbs 70z)
Active fetal movement with cardiac activity at 143 bpm
Adequate amniotic fluid volume ( AFI: 12.86 cm)
 Posterior Placenta Grade II
EDD by ultrasound : October 16, 2019 ( +/-) 10 days

IV. MEDICATION AND IV INFUSION

DOCTOR’S ORDER
Date Progress Note Doctor’s Order

October 13, 2019 A >G5P4 ( 4004 ) PU 40 1/7 weeks NPO

IE: Fully Dilated Fully Efface + BOW IVF:D5LR 1L + 10 unit oxytoxin
LAB: CBC w/ pH counts
HbsAg
Urinalysis
Blood Typing
VS w/ FHT q1
WOF feto material distress

POST PARTUM ORDERS

Perineal Support ( Procedure) - Transfer to NSD WARD
Alive baby boy - DAT when fully awake
Cephalic - Increase Oral fluid intake
- IVF D5LR1L + 10 units oxytoxin to run for
8hrs then to continue

MEDS:
- Pls. give oxytoxin 10 U IM start dose

ORAL MEDS:
1. Amoxicillin 500mg/cap, 1 cap q 8hrs
for 7 days
2. Mefanamic acid 500 mg/ cap, 1 cap q
6hrs for PAIN
3. Ferrous Sulfate cap, 1 cap BID for 30
days
4. Multivitamins cap, 1 cap 2x a day for 30
days
- Monitor VS q 1 for 4hrs then q 4 hr once
stable
- WOF profuse vaginal bleeding
- Keep Uterus contracted
- Perineal hygiene TID using iodine
femine wash
- Encourage BF
- Follow up laboratory result
- Refer accordingly
 Addendum:
October 14, 2019 “ ayaw ko na po dahil takot po ako baka
ikamatay ko ’’
-Follow up BTL tomorrow AM
- NPO past midnight
BP 110/ 80
Hgb 92
IE: w/ minimal lochial discharge
- Follow up IE today
- Repeat H/H
- Pls give 2 amps Iron sucrose
- Monitor VS q 4hr reffered
- Hygiene

MGH after Iron Sucrose

October 15, 2019

Discharge Summary
Admitting Diagnosis: G5P4 ( 4004) PU 40 1/7

Discharge Diagnosis: G5P5 ( 5005) spontaneously to an alive baby boy vertex delivered

Brief Clinical History: Good fetal movement

Uterine Contraction

Course in Ward: Post partum care done

Given antibiotics and pain reliever

Laboratory Findings: CBC w/ pH

Urinalysis

HBsAg

Medication: Oral meds