Republic of the Philippines

City of Olongapo City

GORDON COLLEGE
COLLEGE OF ALLIED HEALTH STUDIES
Olongapo City Sports Complex, Donor St., East Tapinac, Olongapo City 2200
Telefax No.: (047) 602-7175 loc 318
www.gordoncollege.edu.ph

BACHELOR OF SCIENCE IN MIDWIFERY

2nd SEM AY 2021-2022

A CASE STUDY of
21 Years Old G1 P1 (1-0-0-1) Pregnancy Uterine 38 weeks and 5/7 days AOG
Delivered Spontaneously to a Live Baby Girl via Normal Spontaneous Delivery
Body Length of 45 cm, APGAR score 8,9 with Mediolateral Episiotomy.

In Partial Fulfilment of the Course Requirements

In Clinical Practicum 102

Submitted by:

RAMOS, JAYNEA FEB A.

August 4, 2020

INTRODUCTION
 A case of a 21-year-old, female, with a diagnosis of G1 P0 38 weeks and 5/7 days AOG.
She is a residence of Upper Nieves St. Mabayuan, Olongapo City, and was admitted at James
L. Gordon Memorial Hospital on March 18, 2022, at 11:15 in the morning due to labor pains.

Nurturing another life inside one woman’s body is just one of the most amazing
processes that can happen inside a woman’s body. Another is the end-product of it which is
delivery or childbirth. Childbirth, also known as labor and delivery, is the ending of pregnancy
where one or more babies leaves the uterus by passing through the vagina or by Caesarean
section. Cesarean delivery (also called a cesarean section or C-section) is the surgical delivery
of a baby by an incision through the mother's abdomen (belly) and uterus (womb). This
procedure is done when it is determined to be a safer method than a vaginal delivery for the
mother, baby, or both. NSD (Normal Spontaneous Delivery) on the other hand refers to any
delivery of the baby through the vagina without the mechanical assistance of vacuum aspirator
or obstetric forceps and without the use of drugs to induce labor.

Figure 1.1 Normal Delivery and C-Section Illustration

Before the development of technology, natural birth has been the practice all around the
world and had quite a high success rate. But due to lack of technology to support this method,
many have also died. The advancement of technology in the field of medicine provided other
options to women on giving birth. In the broadest definition, Normal Spontaneous Delivery
includes a labor that begins spontaneously, usually between 37 and 42 weeks of pregnancy. It
also includes skin-to-skin holding after delivery, and breastfeeding within the first hour
after delivery.

Labor is a clinical diagnosis. The onset of labor is defined as regular, painful uterine
contractions resulting in progressive cervical effacement and dilatation. Cervical dilatation in the
absence of uterine contraction suggests cervical insufficiency, whereas uterine contraction
without cervical change does not meet the definition of labor.

Obstetricians have divided labor into 3 stages that delineate milestones in a continuous
process. The first stage begins with regular uterine contractions and ends with complete cervical
dilatation at 10 cm.  It is subdivided into an early latent phase and an ensuing active phase. The
latent phase begins with mild, irregular uterine contractions that soften and shorten the cervix.
The active phase, on the other hand is further divided into an acceleration phase, a phase of
maximum slope, and a deceleration phase. The second stage begins with complete cervical
dilatation and ends with the delivery of the fetus while the third stage of labor is defined by the
period between the delivery of the fetus and the delivery of the placenta and fetal membranes. 

Figure 1.2 Stages 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.

The cardinal movements are described as 7 discrete sequences, the engagement,

descent, flexion, internal rotation, extension, restitution & external rotation, and expulsion.

During the 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.

During the engagement stage, 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.

Then, the flexion stage will start 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.

The next part is the 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.

Extension is next in line, 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.
 Second to the last part is the 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.

And the last part is 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.

Figure 1.2: Mechanisms of Labor

After delivery, the newborn is nursed and fed by the mother. Breast milk is the best for the first
six months of life. It is the gold standard for infant feeding.

Figure 1.3: Breastfeeding

In addition to providing nutrition, it protects the baby against infection, and results of less
allergies, healthier growth, better neurodevelopment, and lower rates of chronic disease.
For mother, breastfeeding is economical and convenient. It also helps the uterus
contract to reduce bleeding and reconditions the uterine muscles stretched by pregnancy.
Breastfeeding is a natural method of child spacing and protects the mother from infection,
cancer, diabetes, osteoporosis and rheumatoid arthritis.
Breast milk provides the ideal nutrition for infants. It has a nearly perfect mix of vitamins,
protein, and fat which contains antibodies that help your baby fight off viruses and bacteria.

REFERENCES

https://www.stanfordchildrens.org/en/topic/default?id=cesarean-delivery-92-P07768
https://momcenter.com.ph/2014/12/07/nsd-normal-spontaneous-delivery-or-painless-choose-
your-pregnancy-path/
https://emedicine.medscape.com/article/260036-overview#a4
https://www.webmd.com/parenting/baby/nursing-basics#1

PATIENT’S PROFILE

Patient N is 21 years old, G1 P0. Patient N resides at Upper Nieves St. Mabayuan,
Olongapo City with her live-in partner and parents. Patient N’s religion is Born Again Christian.
She was admitted in James L. Gordon Memorial Hospital on March 18, 2022, at 11:15 in the
morning with a chief complaint of “humihilab po ang tiyan ko” as verbalized by the patient.
Admitting diagnosis: G1P0 PU 38 weeks and 5/7-day AOG, CIL.

MEDICAL HISTORY

On her family history patient N has no allergies with food and medication. She has no
history of serious childhood illness and disease. Minor illnesses such as cough, mild fever, cold,
and flu has been experienced by the patient in her childhood.

FAMILY HISTORY

Patient N and her live-in partner are living together with her parents. She was being taken care
of her own mother as she went to pregnancy until labor. Her mother has hypertension and no
other history of serious illnesses.

SOCIO-ECONOMIC HISTORY

According to Patient N her live-in partner is the breadwinner of their family as he works
at SBMA as Production Operator with an average income of Php 30, 000 per month. They are
allotting the half of their income for her prenatal check-up for her first incoming baby. Her family
and her live-in partner’s family are still supporting them in terms of basic expenditures such as
food and electric bills. Patient N is a non-smoker and only drinks alcohol occasionally.

OBSTETRICAL and GYNECOLOGICAL HISTORY

Her menarche was when she was 12 years of age. Her menstrual duration of 7 days
with a regular cycle of 28 days, with a heavy gradual flow until it moderates to the end of the
period and consuming 3-4 pads a day. Dysmenorrhea is always present only on the first two
days of her menstruation, with a pain scale of 7/10 and take a rest for the rest of the day.
Patient N is on her first pregnancy. Her OB score is G1 P0. Also, she has no history of any
sexually transmitted diseases (STD’s).

REVIEW OF SYSTEMS
 Patient N is consciously awake and coherent. Her initial vital signs were: Temperature of
36.7°C, PR of 93 bpm, RR of 20 bpm and BP of 130/80. Abdomen is globular with a Fundic
Height of 30 cm, below the xiphoid process with her Fetal Heart Tone of 138/min.

Admitting diagnosis: A 21 years old G1P0 (0000) PU 38 weeks and 5/7-day AOG, CIL.

COURSE IN THE WARD

DAY 1 of Hospitalization:
March 18, 2022 (Friday)

At 11:15 AM
Transfer in from Triage to Labor room via wheelchair accompanied by helper on duty
and secure consent for admission and management was signed. Internal Examination was
performed upon admission; IE revealed 6 cm. Abdominal Examination done to Patient N which
revealed Fetal Back at LLQ, and she has been hooked to a fetal monitor which revealed the
Fetal Heart Tone of 138.
Upon her Physical Examination, the expected date of delivery is on March 27, 2022.
Fundic Height of 30 cm, Station is on – 2. and Bag of Water (BOW) is intact.

At 11:30 AM
Her vital was monitored:
Blood pressure of 130/80; temperature of 36.7°C; respiration rate of 20 and a pulse rate of 93.

At 12:00 NN
Patient N’s laboratory test has been requested.

At 1:00 PM, laboratory test was released, and the results are:

EXAMINATION RESULTS REFERENCE VALUE

Hemoglobin 142 Male: 140-180
Female: 120-150
Hematocrit 0.42 Male: 0.40-0.50
Female: 0.30-0.40
WBC 8.55 5.0-10.0 x10⁹/L
Neutrophils 0.66 0.30-0.70
Lymphocytes 0.30 0.20-0.40 %
Monocytes 0.04 0.02-0.10 %
Platelets 249 150-350 x10⁹/L
RBC 4.51 Pedia:3.8-5.4 x1012/L
Adult: 4.6-5.0x1012/L
Interpretation: Hematology results of Patient N are all in normal range.

Requested Result
HbsAg NONREACTIVE
RPR NONREACTIVE
Blood Type “A”
Interpretation: Patient N’s results to the requested tests are all normal.
At 2:00 PM
Patient N was transferred to DR table. She was examined again by midwife on duty and
cervix was revealed 8 cm.
Her vital was monitored:
Blood pressure of 130/80; temperature of 36.7°C; respiration rate of 20 and a pulse rate of 93.
At 2:10 PM
Start an IVF: D5LRS 1L x 30gtts/min, ordered by Dr. Sangalang.

At 4:35 PM
The patient was position in dorsal recumbent position, her internal examination (IE)
revealed at 10 cm cervix, fully dilated, 100% effaced and the bag of water has been ruptured
spontaneously, the color is clear. Patient N starts bearing down. Her vital signs are being
monitored while in active labor progress.

At 5:00 PM
Right mediolateral episiotomy was done to the patient. Patient N spontaneously
delivered to a live baby girl via Normal Spontaneous Delivery (NSD) accompanied by Dr.
Sangalang. APGAR Score of 8,9, newborn weighing 2.5 kgs, body length of 45 cm, head
circumference of 31 cm, chest circumference of 29 cm and abdominal circumference of 26 cm.

At 5:06 PM
Placenta expelled completely. 10 units of oxytocin was administered intramuscularly.
Uterus is well contracted, advised to perform general hygiene and Diet as Tolerated (DAT).

At 5:10 PM
Vital sign was monitored again but now every 15 minutes.

TIME BP PR RR
5:15 PM 130/80 mmHg 90 bpm 21 bpm
5:30 PM 140/80 mmHg 96 bpm 20 bpm
5:45 PM 130/80 mmHg 98 bpm 20 bpm
6:00 PM 130/80 mmHg 97 bpm 20 bpm

At 6:00 PM
Patient N is coherent, conscious, and stable with on-going IVF D5LRS 1L + 10 units of
oxytocin. Dr. Sangalang also advised for Internal Examination after 12 hours. Perineal care was
also advised to Patient N.

At 7:00 PM
Patient N is then monitored for profuse bleeding and brought to ward.

Vital sign was monitored again every 1 hour.

TIME BP PR RR
7:00 PM 130/80 mmHg 95 bpm 20 bpm
8:00 PM 120/80 mmHg 90 bpm 20 bpm
9:00 PM 120/80 mmHg 91 bpm 21 bpm

At 10:00 PM
Patient N was on bed, on diet as tolerated and uterus is well contracted. Breastfeeding
is advised.
 TIME BP PR RR
10:00 PM 120/80 mmHg 89 bpm 19 bpm
11:00 PM 120/80 mmHg 87 bpm 18 bpm

DAY 2 of Hospitalization:
March 19, 2022 (Saturday)

At 6:00 AM
Patient N was on bed, on diet as tolerated and uterus is well contracted. Breastfeeding is
emphasized and discharge Internal Examination done by Dr. Sangalang.

Monitoring of Vital Signs

TIME BP PR RR
6:00 AM 120/80 mmHg 95 bpm 20 bpm
9:00 AM 120/80 mmHg 97 bpm 20 bpm
12:00 PM 120/80 mmHg 97 bpm 20 bpm
3:00 PM 120/80 mmHg 97 bpm 20 bpm

Dr. Sangalang advised Patient N to take Methergine 1 tablet 3 times a day to prevent
and control bleeding from the uterus that can happen after childbirth.

Patient N is in good and stable condition but still in the hospital for securing her bill with
a final diagnosis of 21 years old G1 P1 (1-0-0-1) PU, 38 weeks, and 5/7 days Age of Gestation,
delivered to a live birth baby girl via Normal Spontaneous Delivery (NSD).
 DRUG STUDY

PRENATAL MEDICINE
DRUG DOSE ROUTE INDICATION HOW DOES SIDE
IT APPLIED EFFECTS
TO YOUR
PATIENT?
Ferrous 1 tablet Oral To prevent It is given to Constipation,
Sulfate (325 mg) anemia and the patient stomach
low blood orally once a cramps or
levels for a day to diarrhea
pregnant maintain her
woman. iron
production
Folic 1 tablet Oral To prevent Encourage to High doses
Acid (600 mcg) defects for take orally might cause
the baby’s once a day abdominal
brain and for preventing cramps,
spinal cord of deformities nausea, sleep
development of the fetus. disorders, or
irritability.
Calcium 1 tablet Oral Calcium Given orally Too much
(1,000 mg) helps once a day to calcium may
strengthen reduce cause kidney
baby's rapidly adverse stones and
developing gestational prevent body
bones and outcomes. from
teeth, and absorbing
boosts zinc and iron,
muscle, heart which we
and nerve need to stay
development healthy.
as well.

INTRA-PARTUM MEDICINE
DRUGS DOSE ROUTE INDICATION HOW DOES SIDE
IT APPLIED EFFECTS
TO YOUR
PATIENT?
Oxytocin 10 units IV To control It is Abnormal
bleeding and administered heartbeat,
achieve to left deltoid vomiting and
uterine to help the nausea
contraction uterine to
 contract
D5LRS 1 L x 8 hrs IV For It is inserted Itching,
(Dextrose 5% (30gtts/min) maintenance to promote coughing,
in Lactated of body fluid, rehydration swelling of
Ringer’s nutrition, and the face,
Solution) rehydration hives

POST-PARTUM MEDICINE
DRUGS DOSE ROUTE INDICATION HOW DOES SIDE
IT APPLIED EFFECTS
TO YOUR
PATIENT?
Methergine 1 tablet Oral For It is taken  Hypertension,
(Methylergonovine 3 x a day controlling orally for seizure,
maleate) (0.2 mg) and prevent controlling nausea, and
uterine hemorrhage vomiting
hemorrhage of the uterus
 CONCLUSION

Patient N is a 21-year-old, female, with a final diagnosis of G1 P1 (1-0-0-1). Patient N is

residence of Upper Nieves St. Mabayuan, Olongapo City, and was admitted at James L.
Gordon Memorial Hospital on March 18, 2022, at 11:15 in the morning. Patient N has no
allergies with food and medication and has no history of serious childhood illnesses and
diseases. Minor illnesses such as cough, mild fever, cold and flu has been experienced by the
patient in her neighborhood and childhood. She had her menarche when she was 12 years old.

Her menstrual duration of 7 days with a regular cycle of 28 days, with a heavy gradual
flow until it moderates to the end of the period and consuming of 3 pads a day. Dysmenorrhea is
always present on her first day of menstruation with a pain scale of 7/10 and takes a rest for the
rest of the day.

Her last menstrual period was June 20, 2021, and the expected date of confinement is
on March 27, 2022.

Patient N is on her first pregnancy. Her OB score is G1 P0. Also, she has no history of
any sexually transmitted disease (STD). She had a regular prenatal check-up at Dr. Tubban.
Patient N seeks consultation at James L. Gordon Memorial Hospital at 11:15 in the morning with
the chief complaint of “humihilab po ang tiyan ko” as verbalized by the patient.

Patient N was incorporated 10 units of oxytocin to presents IVF regulated to 30

gtts/mins. Patient N was transfer to the delivery room safely and comfortable. She was assisted
to the delivery table and positioned her in a dorsal recumbent position and continues monitoring
her vital signs. Her internal examination (IE) revealed 10cm cervix, fully dilated and 100%
effaced which is the second stage of labor (Expulsive Stage), where it begins when the cervix is
completely dilated (open) and ends with the birth of her baby. Contractions push the baby down
the birth canal, and she felt intense pressure, like an urge to have a bowel movement.

Patient N delivered a baby girl via Normal Spontaneous Delivery (NSD), accompanied
by Dr. Princess Sangalang, weighing 2.5 kgs, body length of 45 cm, head circumference of 31
cm, chest circumference of 29 cm and abdominal circumference of 26 cm. While waiting for the
discharge paper and to transfer Patient N to the OB ward, VS was monitored, she still has an
on-going IVF of D5LRS 1L + 10 units of oxytocin x 30 gtts/min and well uterine contraction.

Final Diagnosis, Patient N is 21 years old, G1P1 (1-0-0-1), pregnancy uterine, 38 weeks
and 5/7 days age of gestation, delivered to live baby girl via NSD.
 RECOMMENDATION

Patient N delivered spontaneously to a live baby girl via Normal Spontaneous Delivery
(NSD). Patient N should have a complete rest after the delivery for at least one week and follow-
up check-up at the Out-Patient Department as the doctor’s advice. She must maintain perineal
hygiene and she must also clean the sutured area to prevent infection. The postpartum should
eat healthy and nutritious food to have a strong body so that she will be able to take care of her
newborn baby girl.

For her newborn baby she must promote exclusive breastfeeding since breast milk
provides the ideal nutrition for infants. It has a nearly perfect mix of vitamins, protein, and fat
which contains antibodies that will help her baby fight off viruses and bacteria. Also, provide
cord care for about 3-4 times a day to reduce infection and foul smell of the cord and expose to
sunlight at 7:00 am for at least 15 minutes and bath her baby using mild soaps only and provide
needs of her baby. Patient N must also bring her child into the nearest health center for
vaccinations needed for her baby’s immunity. If having a problem or help into her baby’s health,
bring her immediately to the nearest health center or hospital as possible.

Also, Patient N should practice family planning since it is her first pregnancy. For her
next pregnancy, I advise her to have a monthly pre-natal check-up and seek consultations to
her doctor to avoid complications.