Republic of the Philippines

NORTH VALLEY COLLEGE FOUNDATION, INC.

COLLEGE OF NURSING
Lanao, Kidapawan City, Province of Cotabato

NORMAL SPONTANEOUS VAGINAL DELIVERY

(NSVD)

A Case Study Presented to the Faculty of the College of Nursing,

North Valley College Foundation, Inc.

In Partial Fulfillment of the Requirements for the Degree of

Bachelor of Science in Nursing

Submitted by:
LUENGAS, MARY JEAN
MAKIPUTIN, JEZZAMAE
MACALANGGA, KAIRA
MANZANO, SHERIAN
HKAMID, FHARHANA
JULIAN, MAEGAN

April 4, 2024

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 TABLE OF CONTENTS

TITLE PAGE ……………………………………………………………………i

TABLE OF CONTENTS …………………………………………………………ii

ACKNOWLEDGEMENT ………………………………………………………iii

CHAPTER I: INTODUCTION ……………………………………………………6

CHAPTER II: OBJECTIVES …………………………………………………….8

CHAPTER III: PATIENT’S DATA …………………………………………………10

CHAPTER IV: FAMILY BACKGROUND/ HEALTH HISTORY ……………….12

Family Health History …………………………………………………….13

Effects/ Expectations of Illness to Self/ Family

Client’s History

Past Illness/es

Present Illness/es

CHAPTER V: DEVELOPMENTAL DATA ……………………………………….14

CHAPTER VI: DEFINITION OF COMPLETE DIAGNOSIS ………………….17

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CHAPTER VII: PHYSICAL ASSESSMENT …………………………………….20

CHAPTER VIII: ANATOMY AND PHYSIOLOGY ………………………………25

CHAPTER IX: SYMPTOMATOLOGY ……………………………………………29

CHAPTER X: CONCEPT MAP ……………………………………………….32

CHAPTER XI: DOCTOR’S ORDER …………………………………………….36

CHAPTER XII: DIAGNOSTIC EXAM ……………………………………………42

CHAPTER XIII: DRUG STUDY ………………………………………………….51

CHAPTER XIV: SURGICAL PROCEDURE ……………………………………58

CHAPTER XV: NURSING THEORIES ……………………………………….60

CHAPTER XVI: NURSING CARE PLAN …………………………………………63

CHAPTER XVII: DISCHARGE PLAN ……………………………………………72

Medication
Exercise
Treatment
Health Teaching
Out – Patient Schedule
Diet
CHAPTER XVIII: RECOMMENDATION ……………………………………….76

CHAPTER XIX: REFERENCES ………………………………………………77

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 ACKNOWLEDGEMENT

The success of this case study would have not been made possible if it weren’t

for these wonderful people who have assisted and prepared us physically,

emotionally, intellectually, and financially. Allow us, as the case presenters, to

acknowledge and extend our sincere gratitude to the following individuals who helped

make this case study a reality.

To the dean of the College of Nursing, April S. Babol, RN, MAN, Ph.D, who made

this clinical nursing exposure possible. We salute your effort in molding us to become

future registered nurses with competent skills, comprehensive knowledge, and

holistic attitude.

To the program coordinator of the College of Nursing, Willyn B. Adrias RN, MN,

and Leda Paras Pacate RN, for peppering us with the appropriate knowledge and

skills in preparation for our clinical exposures. You have armed us with great

knowledge and understanding with our duties and responsibilities as student nurses.

To our clinical instructor, Jaypee Malibiran, RN, for her unending support,

continuous guidance, inexhaustible patience, meticulous suggestions, and astute

criticism during our ward duty until the day of the case presentation and revisions of

the paper.

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 To the healthcare professionals and staff of Southern Philippines Medical Center,

for their cooperation and giving us the information, we need to have in order to

understand the nature of the disease and the complications that lie or remain to be a

threat in the patient’s health.

To our patient and her family, for their willingness to cooperate during the

interview and kind consideration in allowing us to perform our duties as student

nurses and establish a comprehensive assessment that will provide us with the

significant information needed to construct a firm foundation of our case study and

presentation.

Finally, and above all, our deepest gratitude and praises to God the Almighty, to

whom we dedicate our case study, for the cascading blessings, knowledge and

strength that He endowed upon us from the very beginning to the end of our

successful case study.

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 CHAPTER I

INTRODUCTION

The journey of pregnancy, full of excitement and wonder, is the start of a new

life. It includes the incredible process by which a woman bears and gives birth to a

priceless human being. The normal spontaneous vaginal delivery (NSVD), a

profound and natural experience that represents the strength and beauty of

motherhood, is a crucial part of this journey. Conception is the first step in the

pregnancy process; it is the moment when an egg and sperm unite to form a new life.

The journey of gestation begins as soon as the fertilized egg implants itself into the

uterine lining and lasts for about 40 weeks. The expectant mother experiences a

range of physical and psychological changes during this time, which mirror the

complex process of fetal developmental.

The World Health Organization (WHO) defines normal spontaneous vaginal

delivery (NSVD) as the process of childbirth where a woman goes into labor naturally

and delivers her baby vaginally without the need for medical interventions such as

forceps, vacuum extraction, or cesarean section. WHO advocates for promoting and

supporting NSVD as the preferred method of childbirth when both the mother and

baby are healthy, as it is associated with fewer complications and better outcomes

compared to medically assisted deliveries when not medically indicated. The

emphasis on NSVD stems from the recognition of the physiological process of

childbirth as a natural and inherently safe phenomenon in the majority of cases. The

WHO acknowledges that childbirth is a complex interplay of maternal and fetal

factors, regulated by hormonal, neurological, and biomechanical processes. NSVD

allows these processes to unfold as nature intended, promoting optimal outcomes for

both mother and baby. (WHO)

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 According to the world bank 2020, the global decrease in birth rate has caused

some countries to worry that their current birth rate is not enough to replace the older

generation, which would lead to a population declined. Problems associated with the

population decline include a slowed economy, which can lead to the closing of

businesses from restaurants to public transportation to schools to medical facilities.

To help counteract these concerns, some governments offer financial incentives to

encourage citizens to have children. Low birth rates are attributed to the high costs of

raising a child, people choosing to further their careers over starting a family, and

older average ages for first-time mothers.

According to the Centers for Disease Control and Prevention (CDC), there were

more than 2.5 million vaginal deliveries in 2020. Vaginal deliveries account for about

68% of all births in the United States and 80% of births worldwide.

The importance of this study lies in the possibility it gives nurses to expand

clinical practice and enhance patient outcomes. It assists nurses in identifying

efficient best practices and enhancing patient care—particularly in the birth room. It

assists us as nursing students in learning more about maternal and child nursing.

This case study about patient ACB, 14 years old, gravida 1 Para 1 (1001)

pregnancy uterine 40 1/7 weeks woman in Normal Spontaneous Vaginal Delivery.

She was admitted at Davao del Sur Provincial Hospital last March 22,2024 at 9:26pm

because she feels pain in her lower abdomen. Upon arrival to the Emergency Room

the patient was assessed 5-7 cm cervical dilation examined by Dr. MPD

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 CHAPTER II

OBJECTIVES

General Objectives

This study aims to broaden the knowledge of North Valley College Nursing

Students about Normal Spontaneous Vaginal Delivery by gathering enough

information to serve as a guide for student nurses who will be working on the same

case. It also aims to improve the students’ skills and attitudes toward the nursing

process and procedure management.

Specific Objectives

At the end of the case presentation, the student nurses will be able to:

• Discuss the process of Normal Spontaneous Vaginal Delivery.

• Present the patient’s data.

• Define the complete diagnosis of the patient.

• Conduct and perform patient’s physical assessment according to the patient’s

condition

• Discuss the normal anatomy and physiology of female reproductive system.

• Conduct a drug study on the patient who is giving birth.

• Identify nursing theories and nursing care plan related to normal spontaneous

vaginal delivery.

• Create concept mapping about the physiological changes in normal delivery

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• Provide recommendations for better management about Normal Spontaneous

Vaginal Delivery.

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 CHAPTER III

PATIENT’S DATA

Name code: Patient A

Sex: female

Age: 14 years old

Civil Status: Live-in

Occupation: Student

Address: Purok 5, Barangay Ibo Malalag Davao del Sur

Birthday: November 12, 2009

Nationality: Filipino

Religion: Roman Catholic

Educational Attainment: Junior High school

Room: Ob ward

Bed Number: 2B

Date of Admission: March 22, 2024

Time of Admission: 9:26pm

Vital Signs on Admission:

Temperature: 36.1°C

Respiratory Rate: 20cpm

Pulse Rate: 68 bpm

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Blood Pressure: 110/70 mmHg

Oxygen Saturation: 99%

Date of Discharge: Still Admitted

Chief Complaints: Labor pains

Admission Findings:

Dilatation: 10 cm

Effacement: The cervix gets thinner

Presentation / Position: Cephalic

Bag of water: Intact of bag of water

Station: Engaged

Admitting Physician: Dr. MPD

Final Diagnosis: Gravida 1 Para 0 (1001) Pregnancy uterine delivered term cephalic

live birth Baby Girl by Normal Spontaneous Vaginal Delivery.

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 CHAPTER IV

FAMILY BACKGROUND/HEALTH HISTORY

Genogram

X X X

X
14 y/o

13 y/o 9 y/o

LEGEND:

MALE
X DECEASED

FEMALE

PATIENT

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Health History:

The patient has no underlying diseases together with her family. Patient’s

family members are all known normal deliveries and no past and present illness.

History of Past Illness:

The patient has no known allergy to any foods or drugs, and has no history of

hypertension, or any other illness.

History of Family Illness:

There was no known familial disease in the family.

History of Present Illness:

During the first trimester patient had experience morning sickness like nausea

and vomiting related to her pregnancy. The patient has no past related history food

and drug allergy, no history of past admission. The patient has received inactive flu

vaccine, Tdap vaccine and tetanus toxoid for her immunization. The menstrual cycle

of the patient is normal and regular. Few hours before the admission the patient

complains labor pains which she describes as the contraction of her abdomen with

other associated signs and symptoms. In the evening of March 22, 2024 patient A,

felt moderate pain during the contraction which prompted her family to rushed her in

the Emergency Room, upon arrival to the Delivery Room at 9:26pm, Dr. MPD on

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duty, assisted her and did an internal examination which revealed 4-5 cm cervical

dilatation.

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 CHAPTER V

DEVELOPMENTAL DATA

MERCER’S MATERNAL ROLE ATTAINMENT

THEORY STAGES RESULT AND

JUSTIFICATION

Informal Phase

Maternal role attainment Achieved, “as the patient

This is the period in which
– an interactional and verbalize “Dili pa kaayo kay
the mother begins to
developmental process simpre first time paman
develop her own maternal
occurring over a period of nako”. The patient is still
identity and becomes
time, during which the developing her maternal
more comfortable with her
mother becomes attached identity and slowly learn
decision-making and
to her infant, acquires and adapt with her
mothering skills.
competence in the care- mothering skills”.
(Meighan, 2017)
taking tasks involved in

the role, and expresses

pleasure and gratification

in the role. (Meighan,

2017)

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 PIAGET’S DEVELOPMENTAL STAGE OF THEORY

THEORY STAGES RESULT AND

JUSTIFICATION

Formal Operational

Stage (age 11 and up)

A comprehensive theory Achieved, “the patient

about the nature and At this stage, individuals verbalized “Kasabot

development of human perform concrete naman ko sa akoang

intelligence. The theory operation on things and sitwasyon karon, ma’am”.

deals with the nature of they perform formal A result that the patient is

knowledge itself and how operations on ideas. able to understand her

humans gradually come to Formal logical thinking is situation and capable of

acquire, construct, and use totally free from seeing potential solutions”.

it. (Main, 2021) perceptual and physical

barriers. During this

stage, adolescents can

understand abstract

concept. They are able to

follow any specific kind of

argument without thinking

about any particular

examples. (Main, 2021)

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 ERIKSON’S PSYCHOSOCIAL DEVELOPMENT THEORY

THEORY STAGES RESULT AND

JUSTIFICATION

Identity vs. Role

A transition from childhood Confusion (12-18 years Achieved “the patient

to adulthood, teens may old) verbalized “katong sa una

begin to feel confused or man gud ma’am na wala

During adolescence, the
insecure about themselves pa koy baby deli nako
transition from childhood
and how they fit into society. mahuna huna ang ingana,
to adulthood is most
As they seek to establish a pero karon na ana koy
important. Children are
sense of self, teens may baby ang akung huna
becoming more
experiment with different huna lang kung unsaon
independent and looking
roles, activities, and na nako ang future namo
at the future regarding
behaviors. .(Kender,2023) uban sa akong bana “
careers, relationships,

families, housing.

(Kender,2023)

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 CHAPTER VI

DEFINITION OF COMPLETE DIAGNOSIS

FINAL DIAGNOSIS:

Gravida1 Para1 (1001), pregnancy uterine delivered term cephalic. Livebirth

baby girl by normal spontaneous vaginal delivery.

Normal Spontaneous Vaginal Delivery

Vaginal delivery refers to the birth of offspring in mammals or babies in

humans, through the vagina, also known as the “birth canal”. It is the natural method

of birth. This occurs after a pregnant woman goes through labor. Labor opens, or

dilates, her cervix to at least 10 centimeters. (Cirino,2017)

Labor usually begins with the passing of a woman’s mucous plug. This is a

clot of mucous that protects the uterus from bacteria during pregnancy. Soon after, a

woman’s water may break. This is also called a rupture of membranes. The water

might not break until well after labor is established, even right before delivery. As

labor progresses, strong contractions help push the baby into the birth canal.

(Wilson,2015)

Preparation for delivery should take into account the patient’s parity, the

progression of labor, fetal presentation, and any labor complications. When the fetal

head crowns and delivery is imminent, gentle pressure should be used to maintain

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flexion of the fetal head and to control delivery, potentially protecting against perineal

injury. Once the fetal head is delivered, external rotation (restitution) is allowed. The

anterior shoulder should then be delivered by gentle downward traction in concert

with maternal expulsive efforts. The posterior shoulder is delivered by upward

traction. After delivery, the infant should be wiped dry and kept warm while any

mucus remaining in the airway is suctioned. After delivery, the placenta, umbilical

cord, and fetal membranes should be examined. (Kilpatrick & Garrison, 2013)

GRAVIDA

Refers to the number of times a woman has been pregnant, regardless of the

outcome. This is the number of times an individual has conceived, including any

current pregnancy. More specifically, it includes the total number of pregnancies, not

deliveries, no matter the gestational age or outcome of the pregnancy. (Petre,2019)

PARA

Parity (para) is the number of times a patient has given birth to a viable child.

Abortus is the term used to describe a pregnancy that ended for any given reason,

including both abortions and miscarriages. (Tidy, 2019)

TERM

The concept of “term” gestation provides guidance to clinicians and influences

the public's perceptions about the optimal timing of delivery for a healthy pregnancy.

Currently, a term birth is defined as a delivery that occurs neither preterm nor post

term.

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 The ACOG and SMFM 2018 use these definitions to describe term

pregnancies:

Early term: Your baby is born between 37 weeks, 0 days and 38 weeks, 6 days.

• Full term: Your baby is born between 39 weeks, 0 days and 40 weeks, 6

days.

• Late term: Your baby is born between 41 weeks, 0 days and 41 weeks, 6

days.

• Post term: Your baby is born after 42 weeks, 0 days.

PREGNANCY

Pregnancy occurs when a sperm fertilizes an egg after it’s released from the

ovary during ovulation. The fertilized egg then travels down into the uterus, where

implantation occurs. A successful implantation results in pregnancy. (Cherney et al.,

2023)

CEPHALIC

The cephalic presentation is a birth position where the fetus is head down,

facing backward, with their chin tucked and the back of their head ready to enter the

birth canal. It is one of the variations of how a fetus rest in the womb and is

considered an ideal baby birth position. (Chakravarti, 2017)

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 CHAPTER VII

PHYSICAL ASSESSMENT

This chapter deals with head to toe assessment of the patient this is

systemically using techniques of inspection, palpation, percussion, and auscultation,

36with the used of medical instrument stethoscope, penlight, tape measure,

sphygmomanometer and also the senses.

General Survey

Patient A is received on bed awake, without IVF. Able to cooperate the level of

consciousness of the client with an oriented verbal response to the time, place and

person. The patient appeared to be tired due to lack of sleep after giving birth. The

patient rated the surgical procedure with a pain scale 5 out of 10.

Vital Signs

TEMPERATURE 36.1°C

BLOOD PRESSURE 11O/70 mmHg

PULSE RATE 68 bpm

RESPIRATORY RATE 20 cpm

OXYGEN SATURATION 99%

PAIN SCALE 5 out of 10

Appearance of the Patient

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 The patient appeared to be tired due to lack of sleep after giving birth. Patient

is pallor, no presence of edema, masses, and skin discoloration noted. No other

abnormal findings noted upon inspection.

SKIN

Upon inspection, the patient’s skin on the upper and lower extremities is fair

in color, and pallor with no skin discoloration, and lesions noted. On palpation, there

is no sign of edema noted and the patient’s skin surface appeared to be dry and

warm with a temperature of 36.1°C

HAIR

The hair of the patient upon inspection is distributed equally, thin, shiny in

texture, and black in color. No signs of infection and infestation noted.

HEAD & FACE

Upon inspection, the patient’s head is normocephalic, oval in shape, and the

face is symmetric. No melasma and nevi was noted. Upon palpation, there is no

tenderness in the scalp, no presence of masses, nodules, and lesions was noted.

EYES & EYEBROWS

Upon inspection of the patient’s eyebrows, there is an equal distribution of

hair, symmetrically aligned, and showed equal movement upon raising and lowering

the eyebrows. The patient’s visual acuity appeared clear, pupils are black and round

22
and both are reactive to light accommodation. The patient has a pallor conjunctiva.

No presence of sore and cloudiness noted.

NECK

Upon inspection, there is no presence of skin discoloration and lesions noted.

The patient’s neck has no masses or distended veins noted during palpation.

EARS & HEARING

Upon inspection, the patient’s auricles are symmetrically aligned with each

other and with the outer canthus of each eye. The patient clearly hears and responds

to our inquires during interview. The auricles are firm upon palpation. No discharge

was noted.

NOSE & SINUSES

The patient’s nose is refined in shape, external nose is symmetrical with no

discoloration noted, and nostrils are symmetric. No abnormal discharges was noted.

MOUTH & THROAT

Upon inspection, the patient’s external lips were seen pallor and dry, patient’s

tongue appeared whitish. No obstruction in throat was noted.

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NAIL BED

There is no presence of discoloration and lesions noted upon inspection of

the nails and the nails were properly trimmed. The capillary refill time was within the

normal range.

BREAST & AXILLARY

During inspection, the patient’s nipple is brown in color, the areola is darker

than the nipple, and the skin around is fair in color. The breast became bigger than

before as what the patient verbalized. No presence of lesions and skin discoloration

noted in assessing the breast and axillary. Upon palpation, the breast felt heavy, full,

and tender. Produces milk when pinched.

CHEST & THORAX

In assessing the chest and thorax, it was observed that the chest is

symmetric, warm in temperature, no masses noted, has a low pitch and hallow sound

upon percussion, and no crackles, murmurs, and wheezing heard upon auscultation.

ABDOMEN

Upon inspection, the patient’s abdominal area was still enlarged due to

evolution process. Presence of stretch marks and linea nigra was noted. During

auscultation, normal bowel sounds (click and gurgles sounds) was noted as

evidenced by ultrasound. No masses noted during palpation.

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GENITOURINARY

Upon inspection, patient’s vagina was seen pinkish. The patient’s discharge

for the first three days was dark red and it was pinkish on the fourth day, as

verbalized by the patient. The patient undergone a surgical procedure, right

mediolateral episiotomy after giving birth.

LOWER EXTREMITIES

Patient’s lower extremities has no presence of lesions, edema, and dark

pigmentation was noted upon inspection. No bipedal edema noted during palpation.

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 CHAPTER VIII

ANATOMY AND PHYSIOLOGY

Pregnancy is a remarkable and transformative journey in a woman’s life,

marked by the complex and awe-inspiring process of bringing a new life into the

world. It is a period characterized by physiological, emotional, and hormonal

changes, spanning approximately 40 weeks from conception to childbirth. This period

is divided into three trimesters, each marked by distinct stages of fetal development

and maternal adaptation.

OVULATION

Ovulation is a physiologic process defined by the rupture and release of the

dominant follicle from the ovary into the fallopian tube where it has the potential to

become fertilized. The ovulation process is regulated by fluxing gonadotropic

hormone (FSH/LH) levels. Ovulation is the third phase within the larger Uterine Cycle

(i,e. Menstrual Cycle). The follicular release follows the Follicular phase (i.e.

dominant follicle development) and precedes the Luteal phase (i.e. maintenance of

corpus luteum) that progresses to either endometrial shedding or implantation.

Follicular release occurs around 14 days prior to menstruation in a cyclic pattern if

the hypothalamic-pituitary-ovarian axis function is well regulated. (Holesh, 2023).

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FERTILIZATION

Fertilization is a complex multi-step process that is complete in 24 hours. The

sperm from a male meets an ovum from a female and forms a zygote; this is the

point in which pregnancy begins and leads to a 280-day journey for a female. There

are two ways to track this process, and they differ by the day counting begins. There

are the post-ovulation age and the gestational age, calculated by adding two weeks

to the last menstrual period. There are many steps that both the egg and sperm must

go through for this process to be successful. Furthermore, the fertilized egg itself

goes through drastic changes. This article will detail the process in the following

sections.(Oliver, 2023).

ZYGOTE

Human embryogenesis is a complicated process by which a fertilized egg

develops into an embryo. During the first eight weeks of development, the conceptus

shifts from a single-celled zygote into a multi-layered, multi-dimensional fetus with

primitively functioning organs. The continued growth and increased intra-embryonic

complexity during the first eight weeks of development are highly dependent upon

cell signaling, proliferation, and differentiation. (Khan,2023)

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BLASTOCYST

Blastocyst, a distinctive stage of a mammalian embryo. It is a form

of blastula that develops from a berrylike cluster of cells, the morula. A cavity

appears in the morula between the cells of the inner cell mass and the enveloping

layer. This cavity becomes filled with fluid. The blastocyst differs from the blastula in

that it is composed of two already differentiated cell types, the inner cell mass and

the enveloping layer. (Britannica,2019)

IMPLANTATION

Human embryogenesis is a complicated process by which a fertilized egg

develops into an embryo. During the first eight weeks of development, the conceptus

shifts from a single-celled zygote into a multi-layered, multi-dimensional fetus with

primitively functioning organs. The continued growth and increased intra-embryonic

complexity during the first eight weeks of development are highly dependent upon

cell signaling, proliferation, and differentiation. Due to the intricacies involved, the

development of the human embryo is divided into developmental events by week.

Week 1 is a major part of the germinal stage of development, a period of time that

continues from fertilization through uterine implantation. (Khan,2023)

28
PLACENTA

After fertilization of the sperm and ovum, four cell division leads to a morula

(16 cells). Around the fourth day after fertilization, the morula enters the uterus as a

blastocyst. The blastocyst divides into trophoblast and embryoblast. About 6 to 7

days later, the differentiating blastocyst implants into the uterine decidua. Then, the

trophoblast further divides into the syncytiotrophoblast and cytotrophoblast; together,

these compose the fetal component of the placenta. These two cell types lay on

either side of villi. (Kapilla,2021)

CERVIX

CERVIX

Lowest region of the uterus; it attaches the uterus to the vagina and provides a

passage between the vaginal cavity and the uterine cavity. The cervix, only about 4

centimeters (1.6 inches) long, projects about 2 centimeters into the upper vaginal

cavity. The cervical opening into the vagina is called the external os; the cavity

running the length of the cervix is the endocervical canal; the opening of the

endocervical canal into the uterine cavity, the internal os. The endocervical canal

transports sperm into the uterine cavity, allows the escape of blood from the uterus

during menstruation, and supplies mucus (a thick lubricating protein) to the female

reproductive tract. During childbirth the canal is greatly stretched. (Britannica,2023)

29
 CHAPTER IX

SYMPTOMATOLOGY

SYMPTOMS PRESENT/ABSENT RATIONALE ACTUAL

1st Trimester The body The patient verbalize that

(Week 1- 12) ✅ undergoes many she often has upset

changes like stomach due to morning

hormonal changes sickness, extreme

effect almost every tiredness, cravings and

organs system in mood swings.

the body. These

changes and

trigger symptoms

even in the very

first week of

pregnancy. (WHO)

2nd Trimester (Week Pregnant woman The patient experiencing

13-28) ✅ might notice the back ache and itching of

symptoms like the abdomen that causes

nausea and fatigue stretch marks.

are going away.

But other new,

more noticeable

changes to the

body are now

happening. Your

30
 abdomen will

expand as the aby

continues to grow.

And before this

trimester is over,

the pregnant

woman will feel the

baby beginning to

move.

Some of the same The patient usually has a

3rd Trimester ✅ discomforts the complain of shortness of

(Week 13-week 28) pregnant woman breathing due to the

had in the second baby heaviness,

trimester will “dropping” or moving to

continue. Plus, the lower abdomen, and

many women find trouble sleeping due to

breathing difficult need proper positioning.

and notice they

have to go to the

bathroom even

more often. This is

because the bay is

getting bigger and

it is putting more

pressure on the

organs.

31
 CHAPTER X

STAGES OF LABOR

 First stage: Dilation of the cervix (mouth of the uterus)

 Second stage: Delivery of the baby

 Third stage: Placental Separation

First Stage

The first stage, which takes about 12 hours to complete, is divided into three

segments: a latent, an active, and a transition phase.

The Latent Phase

The latent or early phase begins at the onset of regularly perceived uterine

contractions and ends when rapid cervical dilatation begin. Contractions during this

phase are mild and short, lasting 20 to 40 seconds. Cervical effacement occurs, and

32
 the cervix dilates from 0 to about 3 cm. The phase averages 6 hours in a nullipara

and 4.5 hours in a multipara. A woman who enters labor with a “nonripe” cervix will

probably have a longer than average latent phase.

The Active Phase

During the active phase of labor, cervical dilatation occurs more rapidly,

increasing from 4 to 7 cm at a rate of about 1 cm per hour in nulliparas and 2 cm per

hour in multiparas. Contractions grow stronger, lasting 40 to 60 seconds, and occur

approximately every 3 to 5 minutes. This phase averages 3 hours in a nullipara and 2

hours in a multipara. Show (increased vaginal secretions) and perhaps spontaneous

rupture of the membranes may occur during this time. This phase can be difficult for

a woman because contractions grow so much stronger and last so much longer than

they did in the latent phase that she begins to experience true discomfort.

The Transition Phase

During the transition phase, contractions reach their peak of intensity, occurring

every 2 to 3 minutes with a duration of 60 to 70 seconds, and a maximum cervical

dilatation of 8 to 10 cm occurs. If it has not previously occurred, show will occur as

the last of the mucus plug from the cervix is released. If the membranes have not

previously ruptured, they will usually rupture at full dilatation (10 cm). By the end of

this phase, both full dilatation (10 cm) and complete cervical effacement (obliteration

of the cervix) have occurred. During this phase, a woman may experience intense

discomfort that is so strong, it might be accompanied by nausea and vomiting. She

may also experience a feeling of loss of control, anxiety, panic, and/or irritability.

Because of the intensity and duration of the contractions, it may seem as though

labor has taken charge of her. Her focus turns entirely inward to the task of birthing

her baby. As a woman reaches the end of this stage at 10 cm of dilatation, unless

33
 she has been administered epidural anesthesia, a new sensation, the irresistible urge

to push, usually begins.

Second Stage

The second stage of labor is the time span from full dilatation and cervical

effacement to birth of the infant. With uncomplicated birth and without epidural

anesthesia this stage takes about 1 hour (Friedman, 1978). A woman typically feels

contractions change from the characteristic crescendo– decrescendo pattern to an

uncontrollable urge to push or bear down with each contraction as if to move her

bowels. The mother pushes with such force that she perspires and the blood vessels

in her neck become distended. The fetus begins descent and, as the fetal head

touches the internal perineum to begin internal rotation, her perineum begins to bulge

and appear tense. The anus may become everted, and stool may be expelled. As the

fetal head pushes against the vaginal introitus, this opens and the fetal scalp appears

at the opening to the vagina and enlarges from the size of a dime, to a quarter, then

a half-dollar. This is termed crowning. Pain may disappear as all of her energy and

thoughts are directed toward giving birth. As the fetal head is pushed out of the birth

canal, it extends, then rotates to bring the shoulders into the best line with the pelvis.

The body of the baby is then born.

The Third Stage

The third stage of labor, the placental stage, begins with the birth of the infant

and ends with the delivery of the placenta. Two separate phases are involved:

placental separation and placental expulsion. After the birth of the infant, the uterus

can be palpated as a fi rm, round mass just below the level of the umbilicus. After a

few minutes of rest, uterine contractions begin again, and the organ assumes a

34
 discoid shape. It retains this new shape until the placenta has separated,

approximately 5 minutes after the birth of the infant.

Placental Stage

As the uterus contracts down on an almost empty interior, there is such a

disproportion between the placenta and the contracting wall of the uterus, that folding

and separation of the placenta occur. Active bleeding on the maternal surface of the

placenta begins with separation, which helps separate the placenta still further by

pushing it away from its attachment site. As separation is completed, the placenta

sinks to the lower uterine segment or the upper vagina. The placenta has loosened

and is ready to deliver when:

• There is lengthening of the umbilical cord.

• A sudden gush of vaginal blood occurs.

• The placenta is visible at the vaginal opening.

• The uterus contracts and feels firm again.

Approximately 80% of placentas separate and present in this way. Appearing

shiny and glistening from the fetal membranes, this is called a Schultze presentation.

If, however, the placenta separates fi rst at its edges, it slides along the uterine

surface and presents at the vagina with the maternal surface evident. It looks raw,

red, and irregular, with the ridges or cotyledons that separate blood collection spaces

evident; this is called a Duncan presentation.

Placental Expulsion

Once separation has occurred, the placenta delivers either by the natural

bearing-down effort of the mother or by gentle pressure on the contracted uterine

fundus by the primary health care provider (a Credé maneuver). Pressure should

never be applied to a uterus in a noncontracted state, because doing so could cause

35
the uterus to evert (turn inside out), accompanied by massive hemorrhage (Stevens

& Wittich, 2011). If the placenta does not deliver spontaneously, it can be removed

manually. It needs to be inspected after delivery to be certain it is intact and part of it

was not retained (which could prevent the uterus from fully contracting and lead to

postpartal hemorrhage).

CHAPTER XI

DOCTOR’S ORDER

Date Doctor’s Order Rationale

Ordered

 Please admit as -Knowing your physician allows them to

03/22/2024 service care deliver you individualized care based on

8:30 your preferences as his patient as well as

their areas of expertise.

 Secure consent to -To ensure ethical and legal standards are

care upheld, and to respect individuals’

autonomy and right to make informed

36
 decisions about their own healthcare.

-This approach is used to support optimal

nutrition while considering the patient's

 DAT ability to consume and digest food without

causing discomfort or complications. It

allows for flexibility in adapting the diet to

the patient's condition, promoting better

adherence and overall well-being.

 Labs; -To ensure that their health status remains

 CBC PLT stable and within acceptable parameters

 Blood before the procedure. It helps identify any

typing changes in vital indicators or potential

 UA issues that may impact the surgery or

 RBS anesthesia.

Regular monitoring through repeated

 HBsAG
laboratory tests allows healthcare

providers to make informed decisions,

optimize patient safety, and adjust the

surgical plan if necessary.

> This is done to maintain the fluid and

electrolvtes balance of the patient as well as

it will serve as the partial for IVTT medicine

 IVF: D5LR 1L
and it is regulated at 20 gtts/min to prevent
@20gtts/min
toxicity and circulatory overload.

37
 >continue vital sign monitoring to improve

rapid response at time.

 VS q hourly

>identification of FHR changes potentially

associated with inadequate fetal

oxygenation, such as changes in baseline

rate, frequent decelerations, and/or

 FHT q30 minutes absent/minimal variability, may enable

timely intervention to reduce the likelihood

of hypoxic injury or death.

> to recognize incipient problems, so that

their progression to serious problems may

be prevented.

 Monitor progress >Referring accordingly ensures that

of labor specialized healthcare professionals can

assess and manage specific aspects of the

patient's health, optimizing their overall

 Refer accordingly condition before the operation and

enhancing the safety and success of the

procedure.

38
03/22/24  IVF: D5LR 1L + 10 > This is done to maintain the fluid and

9:26 Pm unit oxytocin @20 electrolvtes balance of the patient as well as

cc/hr it will serve as the partial for IVTT medicine

and it is regulated at 20 gtts/min to prevent

toxicity and circulatory overload.

>This approach is used to support optimal

POSTPARTUM nutrition while considering the patient's

ORDER ability to consume and digest food without

 DAT causing discomfort or complications. It

allows for flexibility in adapting the diet to

the patient's condition, promoting better

adherence and overall well-being.

 Meds: >These medications aim to address

specific medical concerns and optimize the

patient's health status after the delivery.

°Oxytocin 10 units IM >It facilitate childbirth.

now

>it inhibits the third and last stage of

o Cefuroxime bacterial cell wall synthesis.

500mg BID

PO

>treatment of mild to moderate pain and

help relieve symptoms of arthritis

o Celecoxib

39
 200 mg 1

tab BID PO >continue vital sign monitoring to improve

rapid response at time.

 Vs q 15 minutes

x 2 Hours the >continue vital sign monitoring to improve

q4H once stable rapid response at time.

 Keep uterus well

contracted

 Must void

spontaneously >there is no longer the pressure from the

on her before 6 gravid uterus onto a hypotonic bladder

hours which may increase the hormonal effect

postpartum and lead to incomplete emptying.

 Breastfeed baby

q2H or earlier

per demand. > breastfeeding also promotes good

health in mothers including reduced risk of

breast and ovarian cancer, maternal

obesity, diabetes, hypertension, and

coronary heart disease.

 Daily perineal

hygiene

>To improve normal perineal secretion and

odors. To prevent infection; To

40
 render perineum clean before and after

childbirth as well as any treatment, surgery

or procedure involving the perineal area.

 To ward once

with vacancy > This is done to maintain the fluid and

electrolvtes balance of the patient as well as

it will serve as the partial for IVTT medicine

and it is regulated at 20 gtts/min to prevent

toxicity and circulatory overload.

TF: D5LR 1L + 10unit

oxytocin @ 20 cc/h

3/23/2024  IVF to continue

 Follow up

Ultrasound

Negative

Bleeding  Continue PO

meds.

41
 CHAPTER XII

DIAGNOSTIC EXAM

HEMATOLOGY

DATE TEST RESULT UNIT NORMAL CLINICAL NURSING

VALUE SIGNIFICANCE RESPONSIBILITIES

09/25/23 WBC 15.86 10^9/L 4.00- The patient’s >Encourage the

10.00 white blood patient for intake of

11:35am cells is 15.86 protein-rich and

where the calorie-rich foods

normal value is and encourage a

4.00 to 10.00. balanced diet.

42
 >Administer

medication as

prescribed by the

doctor.

Neu% 79.8 % 50.0-70.0 The patient’s >Encourage patient

neutrophils is for intake of foods

79.8 where the that are rich in

normal value is vitamin C, D, and

50.0 to 70.0. zinc.

>Administer

medication as

prescribed by the

doctor.

Lym% 14.6 % 20.0-40.0 The patient’s >Encourage patient

lymphocytes is for intake of foods

14.6where the that are rich in

normal value is vitamin C, D, and

20.0 to 40.0. zinc.

>Administer

medication as

prescribed by the

doctor.

Mon% 4.7 % 3.0-12.0

43
Eos% 0.9 % 0.5-5.0

Bas% 0.0 % 0.0-1.0

RBC 3.68 10^12/L 3.50-5.50

HGB 98 g/L 110-160 The patient’s >Encourage the

hemoglobin test patient to eat

is 98 where the foods that is high

normal value is in iron, such as

110 to 160. egg, meat and

green leafy

vegetables.

>Administer

medication as

prescribed by the

doctor.

HCT 30.1 % 37.0-54.0 The patient’s >Encourage the

hematocrit is patient for intake of

30.1 % where protein-rich and

the normal calorie-rich foods

value is 37.0 to and encourage a

44
 54.0 balanced diet.

>Administer

medication as

prescribed by the

doctor.

MCV 81.9 fL 80.0-

100.0

MCH 26.8 Pg 27.0-34.0 The patient’s > Encourage the

mean patient to eat

corpuscular foods like fish,

hemoglobin is green leafy

26.8 where the vegetables, liver

normal value is and fortified

27.0 to 34.0. cereals.

>Administer

medication as

prescribed by the

doctor.

MCH 327 g/L 320-360

RDW- 14.8 % 11.0-16.0

CV

PLT 324 10^9 /L 150-450

45
 ABO B

RH POSITIVE Monitor and manage

patient’s

manifestations.

DATE TEST RESULT UNIT NORMA CLINICAL NURSING

L VALUE SIGNIFICANCE RESPONSIBILITIES

09/25/23 WBC 19.64 10^9/L 4.00- The patient’s >Encourage the

10.00 white blood patient for intake of

6:53pm cells is 19.64 protein-rich and

where the calorie-rich foods

normal value is and encourage a

4.00 to 10.00. balanced diet.

>Administer

medication as

prescribed by the

doctor.

Neu% 84.4 % The patient’s >Encourage patient

50.0-70.0 neutrophils is for intake of foods

84.4 where the that are rich in

normal value is vitamin C, D, and

50.0 to 70.0. zinc.

>Administer

46
 medication as

prescribed by the

doctor.

Lym% 10.5 % 20.0-40.0 The patient’s >Encourage patient

lymphocytes is for intake of foods

10.5 where the that are rich in

normal value is vitamin C, D, and

20.0 to 40.0. zinc.

>Administer

medication as

prescribed by the

doctor.

Mon% 5.0 % 3.0-12.0

Eos% 0.1 % 0.5-5.0 The patient’s >Encourage the

eosinophils is patient by eating a

0.1 where the healthy diet by

normal value is including more fruits

0.5 to 5.0. and vegetables and

avoiding acidic

foods.

>Administer

medication as

prescribed by the

47
 doctor.

Bas% 0.0 % 0.0-1.0

RBC 3.26 10^12/L 3.50-5.50 The patient’s >Encourage

RBC test is patient to eat iron

3.26 where the rich foods like fish,

normal value is green leafy

3.50 to 5.50. vegetables, beans

and nuts.

>Administer

medication as

prescribed by the

doctor.

HGB 87 g/L 110-160 The patient’s >Encourage the

hemoglobin test patient to eat

is 98 where the foods that is high

normal value is in iron, such as

110 to 160. egg, meat and

green leafy

vegetables.

>Administer

medication as

prescribed by the

doctor.

HCT 30.1 % 37.0-54.0 The patient’s >Encourage the

hematocrit is patient for intake of

48
 30.1 % where protein-rich and

the normal calorie-rich foods

value is 37.0 to and encourage a

54.0 balanced diet.

>Administer

medication as

prescribed by the

doctor.

MCV 81.5 fL 80.0-

100.0

MCH 26.7 Pg 27.0-34.0 The patient’s > Encourage the

mean patient to eat

corpuscular foods like fish,

hemoglobin is green leafy

26.7 where the vegetables, liver

normal value is and fortified

27.0 to 34.0. cereals.

>Administer

medication as

prescribed by the

doctor.

MCHC 328 g/L 320-360

RDW- 14.6 % 11.0-16.0

CV

49
URINALYSIS

CHEMICAL RESULT RATIONALE

COLOR STRAW The patient’s urine color is

straw which is normal.

TRANSPARENCY HAZY The patient’s urine

transparency is hazy which is

normal.

REACTION ACIDIC The patient’s urine reaction is

acidic which indicates a sign

of urinary tract infection.

SUGAR NEGATIVE The patient’s level of urine

glucose has no any

implications.

ALBUMIN NEGATIVE There are no any presence of

albumin in the patient’s urine

which is normal.

SPECIFIC GRAVITY 1.010 The patient’s specific gravity

level of urine is normal.

EPITHELIAL TISSUES MODERATE The urine of the patient

showed a moderate presence

of epithelial tissues which

indicates a sign of urinary

50
 tract infection.

RBC 0-2/HPF The RBC of the patient is 0.2

per HPF where the normal

value is 4.

51
 CHAPTER XIV

SURGICAL PROCEDURE

RIGHT MEDIOLATERAL EPISIOTOMY

A right mediolateral episiotomy and episiorrhaphy are surgical procedures

commonly performed during childbirth or to repair perineal tears. Right mediolateral

episiotomy is a surgical incision made in the perineum, the area between the vagina and

the anus, during childbirth. It refers to an incision made at a 45-degree angle to the

midline on the right side of the perineum. This procedure is typically performed when

there is a risk of perineal tearing during childbirth. It may be recommended in cases

where the baby's head is large or if there is concern about prolonged labor that could

lead to extensive tearing. The episiotomy is performed by making a precise incision in

the perineum, usually during the later stages of labor just before the baby is delivered.

The angle and location of the incision are important to minimize trauma and facilitate

healing. (Berkowitz LR, et al. 2018)

EPISIORRAPHY

Episiorraphy is the surgical repair of an episiotomy or perineal tear after

childbirth. It involves suturing the incision or tear to promote healing and restore the

integrity of the perineum. This procedure is necessary following an episiotomy or when

there are tears in the perineum that require repair. The severity of the tear will determine

the extent of the repair needed. Episiorraphy is performed under sterile conditions. The

52
surgeon carefully sutures the edges of the episiotomy or tear, ensuring proper alignment

and closure of the wound. Absorbable sutures are often used, which do not need to be

removed and dissolve over time as the tissue heals. (Barjon K, Mahdy H. 2021)

The type and extent of the episiorraphy will depend on the nature and severity of

the perineal tear or episiotomy. After the procedure, patients are typically provided with

instructions for postoperative care, including hygiene, pain management, and monitoring

for any signs of infection or complications. The stitches used in episiorraphy are usually

designed to dissolve on their own over time, so additional removal is not typically

required.

These surgical procedures are important in managing perineal trauma during

childbirth and promoting optimal healing and recovery for the mother. They are

performed with careful consideration of the individual's medical needs and are part of the

comprehensive care provided during labor and delivery.

53
 CHAPTER XV

NURSING THEORIES

BETTY NEUMAN THEORY

Betty Neuman is a prominent nurse theorist known for developing the Neuman

Systems Model. Her theory focuses on the individual as an open system that interacts

with their environment to maintain stability and well-being. Neuman's Systems Model

guides nursing practice by emphasizing the nurse's role in assessing the person's

stability, identifying stressors, and implementing interventions to promote adaptation and

maintain or restore balance. Nurses provide holistic care that considers the person's

physical, psychological, sociocultural, and spiritual [Link] the context of normal

spontaneous vaginal delivery (NSVD), nurses can apply Neuman's Systems Model by

assessing the woman's stability and identifying potential stressors that may arise during

labor and delivery. This includes evaluating the woman's physiological status, emotional

well-being, social support, and cultural beliefs and practices. Nurses can then implement

interventions to reduce stressors, enhance the woman's lines of defense, and promote

adaptation during [Link] using Neuman's Systems Model, nurses can provide

comprehensive care that considers the woman's holistic well-being and promotes

stability and adaptation during NSVD. The model helps guide the assessment,

intervention, and evaluation process, ultimately supporting positive outcomes for both

the woman and her newborn. ( Alligood, M. R. 2013)

54
MADELEINE LENINGER THEORY

Madeleine Leininger is a prominent nursing theorist known for her Theory of

Culture Care Diversity and Universality. Leininger's theory emphasizes the importance of

understanding and integrating cultural care into nursing practice. She believed that

culture plays a significant role in shaping an individual's health beliefs, practices, and

experiences. Leininger's Theory of Culture Care Diversity and Universality guides

nursing practice by emphasizing the need for culturally sensitive and appropriate care.

Nurses should strive to understand the cultural context of their patients, including their

beliefs, values, and healthcare practices. By integrating cultural care into their practice,

nurses can promote effective communication, build trust, and enhance patient

[Link] the context of normal spontaneous vaginal delivery (NSVD), nurses can

apply Leininger's theory by recognizing the cultural influences on childbirth practices and

beliefs. They can engage in culturally competent care by respecting and accommodating

the woman's cultural preferences during labor and delivery. This may include

incorporating cultural rituals, involving family members in the birthing process, and

providing education that aligns with the woman's cultural beliefs and [Link]

integrating Leininger's Theory of Culture Care Diversity and Universality into nursing

practice, nurses can provide culturally sensitive and patient-centered care during NSVD.

This approach promotes positive patient experiences, enhances communication, and

improves overall outcomes for women and their families. (McFerland, M. R. 2018)

55
JEAN WATSON THEORY

Jean Watson is a renowned nurse theorist known for her Theory of Human

Caring. Watson's theory emphasizes the importance of a caring relationship between the

nurse and the patient, focusing on the humanistic aspects of nursing care. She believes

that caring is central to nursing and has the power to promote healing, growth, and well-

being. ean Watson's Theory of Human Caring has influenced nursing practice,

education, and research. It emphasizes the importance of a caring presence,

compassion, and therapeutic communication in promoting healing and well-being. By

integrating the principles of caring into their practice, nurses can create a caring

environment that supports the physical, emotional, and spiritual needs of the [Link]

the context of normal spontaneous vaginal delivery (NSVD), nurses can apply Watson's

theory by establishing a caring and trusting relationship with the woman. They can

provide emotional support, promote comfort measures, and respect the woman's

autonomy and choices throughout the birthing process. By being present and attentive,

nurses can create a caring environment that promotes a positive childbirth

[Link]'s important to note that Jean Watson's theory is just one of many nursing

theories available, and different theories may be more appropriate in specific contexts or

for specific patient populations. (Sitzman, K. 2018)

56
 CHAPTER XVII

DISCHARGE PLAN

This chapter deals with the instruction and advice given by the patient A and

significant others upon discharge on March 24, 2024 from Davao del Sur Provincial

Hospital. With, this may enable best delivery of care to the patient in transition from

hospital to home.

Nursing Order Discharge Plan Rationale

Hycosine N- butylbromide -Treatment for abdominal
Medication
(HnBB)1 ampule pain associated with

IVTT cramps induced by

gastrointestinal (GI) spasm.

-Prevents excessive
Oxytoxin 1 ampule IM
bleeding by helping the

uterus to contract

Cefuroxime 500mg BID -Treatment of patients with

various postnatal disease

and postpartum

complications.

Celecoxib 200mg 1 tab -Used to treat mild to

BID
moderate pain and help

relieve symptoms of

Patient- controlled epidural

analgesia ( PCEA)

57
Exercise -Instruct the patient no -Performing intense

heavy lifting for 4 weeks physical activities such as

running or lifting heavy

weights too soon can lead

to further postpartum

complications and delay

the recovery of joints and

ligaments throughout the

body.

-Instruct the patient to do -This yoga pose can help

happy baby yoga pose and relax and gently

stretch your muscle to

relieve pain

-Exercising after you have

-Encouraged the patient
your baby can improve
for walking but no
your physical and mental
strenuous activity prior to 2
wellbeing. And also it can
weeks postpartum
help to restore muscle

strength and firm up your

body.

Treatment -Instruct the patient to do -To prevent infection to the

perineal care and the area and inhibit cross

importance of proper contamination

perineal cleaning

58
 -Instruct the mother on

how to cleaned the -Alcohol can irritates the

umbilicus, she should skin and sometimes it can

clean with water not baby delays healing.

oil or alcohol.

Health teaching

-Encouraged the patient to -To have an adequate rest

get an adequate rest it will help you to recover

immediately.

-Instruct the patient to -Breast milk helps to keep

breastfeed the baby every your baby healthy and also

2 to 4 hours it supplies all the necessary

nutrients in the proper

proportions.

-Instruct the mother to -Breast massage may help

massage the breast and to ease a range of

apply warm moist towel if conditions, from plugged

the breast feels engorged milk ducts to sore muscle,

and applying warm moist

towel is one way to release

breast engorgement.

59
 -Instruct the patient for -Postpartum check ups
Outpatient scheduled
follow- up check up after 1 allows you to share any

week of postpartum concerns you have with

your care team and allows

them to look for warning

signs of serious health

problems.

CHAPTER XVIII

RECOMMENDATION

60
 We had a lot of experience that shaped us to be more skilled and the best

version of ourselves as future nurses after being exposed to the hospital and interacting

with the complete patient. Following the analysis of our study, we came up with the

following suggestions, which will also serve as a learning aid for the patient and may be

helpful during her recovery.

The patient is urged to adhere to the discharge instructions created and provided by the

medical staff while in the health rehabilitation phase. The patient’s cooperation is

essential to her resumed everyday activities.

The patient’s family is expected to help the sufferer in whatever way they can to regain

their health, whether that be through physical, psychological, social, or spiritual growth.

CHAPTER XIX

REFERENCES

61
ACOG and SMFM (2018). What is a full-term pregnancy?

Britannica, T. Editors of Encyclopedia (2020, February 18). Blastocyst. Encyclopedia

Britannica. [Link]

Britannica, T. Editors of Encyclopedia (2023, September 15). Cervix. Encyclopedia

Britannica. [Link]

Healthline, Medical News Today (2017, June 5). Spontaneous Vaginal Delivery

[Link]

Office on Women's Health. (2010). Stages of pregnancy. Retrieved May 20, 2016, from

[Link]

Spong, C. Y. (2013). Defining "term" pregnancy: Recommendations from the Defining

"Term" Pregnancy Workgroup. JAMA, 309(13), 2445–2446. Retrieved October 28, 2013,

from [Link] external link

NICHD. (2013). Carrying pregnancy to 39 weeks: Is it worth it? Yes! Retrieved July 8,

2016, from [Link]

[Link]

NICHD. (2013). Redefining the term. Retrieved July 8, 2016, from

[Link]

Kapila V, Chaudhry K. Physiology, Placenta. [Updated 2023 Jul 24]. In: StatPearls

[Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from:

[Link] YS, Ackerman KM. Embryology,

Week 1. [Updated 2023 Apr 17]. In: StatPearls [Internet]. Treasure Island (FL):

StatPearls Publishing; 2023 Jan-. Available from:

[Link]

62
63