1. Republic of the Philippines
City of Olongapo
GORDON COLLEGE
AY 2012-2013
A Case Study of G1P1(1001) PU 38weeks Delivered Spontaneously to a
Live Baby Boy with Repair of RMLE
In partial Fulfillment of the
Course requirement in Clinical Practicum 201
Submitted to:
Mrs. Sandra Rivera
Mrs. Claire Cruz
Ms. March Paneza
Submitted by:
Magno,Vivian Estella

2. INTRODUCTION:
NORMAL SPONTANEOUS DELIVERY
Normal Spontaneous delivery (NSD) also called Vaginal Delivery is a medical term used to
describe when a pregnant woman goes into labor without the use of drugs or techniques to
induce labor, and delivers her baby in the normal manner, without a cesarean section. In other
words, it is the natural birth of a child, simply without the intervention of modern techniques
devised by humans.
The general motive behind choosing to proceed with a NSD rather than a modern delivery is of
concern over the possibility of artificial methods having an unnatural and unintended harmful
effect on the infant. It is widely accepted that synthetic medical drugs have been observed to
produce adverse health effects and as such the FDA attempts to enforce disclosure of these
effects to consumers, when the effects are deemed statistically significant. In addition to these
known risks, medication carries with it the risk of causing harm in ways not currently known or
understood. Although most professionals in the medical industry would contend that such risks
are often negligible, being that drug use is so common, there are however many holistic
practitioners, other professionals, and members of the public which disagree with this contention
and are not willing to take the risk. Afterall, an infant child is a fragile creature, intimately
connected to the health of its mother.
As for pain management, one may consider the most natural approach to be a healthy diet, high
in antioxidants, anti-inflammatories, essential fatty acids (omega-3), etc. The psychological
factor can also be effected through more-natural means, through something as simple as
learning to stay calm, or through procedures such as hypnosis. Some might consider taking
certain plants ("herbs") not normally considered food, with the intention of having them function
as natural pain killers. This approach however might not be considered acceptable by those
striving for as natural a process as possible, as it is possible for herbs to contain biochemicals
which function very similarly to synthetic chemical drugs.
What is false labor?
As you approach your due date, the painless and infrequent Braxton Hicks contractions
that you may have been feeling since mid-pregnancy sometimes become more

3. rhythmic, relatively close together, and even painful, possibly fooling you into thinking
you're in labor. But unlike true labor, this so-called false labor doesn't cause significant,
progressive dilation of your cervix, and the contractions don't grow consistently longer,
stronger, and closer together.
How Do I Know When Contractions Indicate True Labor?
To figure out if the contractions you are feeling are the real thing and you're going into labor, ask
yourself the following questions.
How often do the contractions happen?
False Labor: Contractions are often irregular and do not get closer together.
True Labor: Contractions come at regular intervals and last about 30-70 seconds. As
time goes on, they get closer together and stronger.
Do they change with movement?
False Labor: Contractions may stop when you walk or rest, or may even stop if you
change positions.
True Labor: Contractions continue despite movement or changing positions.
How strong are they?
False Labor: Contractions are usually weak and do not get much stronger. Or they may
be strong at first and then get weaker.
True Labor: Contractions steadily increase in strength.
Where do you feel the pain?
False Labor: Contractions are usually only felt in the front of the abdomen or pelvis.
True Labor: Contractions are more intense and may start in the lower back and move to
the front of the abdomen.

5. PATIENT’S PROFILE:
In keeping my patient privacy, I want to hide her true identity. Just called her Mrs. A.
Mrs.A a 23 years of age who live at Castellejos Zambales . She is a house wife and her
husband work was an operator in Hangin.Her height was 153cm and weight 48kg.
Mrs.A, first prenatal check-up was, on her three(3) months of her pregnancy, at Lying-in in San.
Marcelino Zambales.
Mrs.A 23 years of age G1P0,Last Menstrual Period( LMP )was on December 20, 2011,
Expected Date of Confinement( EDC ) on September 27, 2012 with 38weeks Age of
Gestation(AOG). Mrs. A Menarche when she was 12yeas old, interval was regular, and duration
for 3-5days. At the age of 18 that was Mrs. A, first Coitarche; she has only one partner.
Day 1, At 1:00pm of September 14, 2012, Mrs. A admitted to James L. Gordon Memorial
Hospital(JLGMH), due to her Chief Complaint(CC) “medyo madalas na po ang hilab ng tiyan ko”
as verbalized by the patient.
Mrs. A admitting diagnosis was 23years old G1P0 PU 38 1/7weeks and her admitting Vital
Sings(V/S) was Blood Pressure(BP) 120/80mmHg, Respiration Rate(RR) 21bpm, Pulse
Rate(PR) 81 bpm, Temperature 36.5C. Her Fundic Height(FH) was 34cm, Fetal Heart
Tone(FHT) 148bpm.
Upon her admission Mrs. A first Internal Examination(IE), was 2cm dilated, 20% ephasement.
September 14, 2012 9:00 PM, Mrs. A trans-in from Emergency Room(ER) via wheel
chair accompanied by Nurse on Duty(NOD) with on going IVF of D5LR 1/L x20gtts/min.; for
HNBB 20mg/ml, 2amp IV; then q4, incorporated 10units oxytoxin to another 1L x 10-15gtts/min.
IE repeated at 9pm and dilated to 8cm, examine by Dr. Corpuz, cervix almost fully dilated. Mrs
A transperred from Emergency Room( ER) to Delivery Room(DR) table safely.
At 10:43pm Mrs. A is for Urinalysis Exam(U/A):
MACROSCOPIC EXAM:
MACROSCOPIC RESULT
COLOR: Amber
TRANSPARENCY: Turbid
SPECIFIC GRAVITY: 1010
REACTION: Acidic
PROTEIN: Trace
GLUCOSE: Trace

6. MICROSCOPIC EXAM RESULT
WBC: (0-2/hpf)- 4-8
RBC: (0-1/hpf) too numerous to count
EPITHELIAL CELLS: Occasional
BACTERIA: Occasional
Mrs.A started starts bearing down, at 4:21am, Mrs.A delivered Spontaneously to a live term
Baby Boy. At 4:22am, 1amp oxytocin was given to Mrs.A through Intra Muscular(IM). At
4:25am, Placenta was completely out; with RMLER sutured layer by layer under local
anesthesia.
At 5:30am, Mrs.A was transferred from Delivery Room(DR) from OB Ward. The Diet of Mrs.A
was Diet as tolerated once fully awake.
Mrs.A final diagnosis was 23y/o(1001) PU delivered to a live baby boy AS 8&9. Birth Weight
2.55kg, Birth Length 47cm, Head Cicumference 33cm, Chest Circumference 29cm, Abdominal
Circumference 25cm.
Day 2, At 1:00am of September 15,2012 Mrs. A is for HEMATOLOGY EXAMINATION.
EXAMINATION RESULT NORMAL VALUES
Blood Type O
Hemoglovin 113 M:140-180 F:120-150
Hematocrit 0.34 M:0.40-0.50 F:0.30- 0.40
WBC COUNT 9.3 5.0-10.0 x10/L
NUETROPHILS 0.74 0.30-0.70
LYMPHOCYTES 0.26 0.20-0.40
PLATELET 217 150-350 X 10/L
September 15, 2012, Mrs. A for SCROLOGY IMMUNOLOGY TEST.
TEST RESULT
HBsAG non-reactive
SYPHILIS non-reactive
At 8:00am Mrs.A was on going to IVF of D5LRS 1L + 20units of oxytocin x 8hrs at 150cc level.
Day 3, September 16, 2012, Mrs. A should consummed her IVF D5LRS x 30gtts/min.

7. DRUG STUDY
MEDICINE DOSAGE ROUTE
HNBB 20mg/ml
Co- Amoxiclav 625mg Oral
Mefenamic Acid 500mg Oral
Ferrous Fumarate
Methelergometrine 0.125g Oral
Malunggay + Folic Cal.
Poyllium Powder ½ glass of cola H2O Oral
CONCLUSION:
I therefore conclude that my patient is a 23y/o, G1P1 a Primipara, delivered spontaneously
to a live Baby Boy.
RECOMMENDATION:
I want to recommend for my clients for her Perineal Hygiene ,Breas feeding as early as birth
until 2y/o. Administer green leafy, vegetable, vit.c rich food, for breast milk. Liberal intake of
yellow fruits and vegetables , particularly among pre-school (3-6y/o). And consumption of
animal source of protein (meat, fish, milk, egg, and utilized iodized salt).