Module 4: Case Study
1.1 Module 4: Case Study
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1.2 Case Study: Mrs FH
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In this case study you will be asked to work through a presented case that progresses
through the antenatal and intrapartum period.
You can make notes throughout the case study and compare your notes with the model
answers provided.
It should take approximately 25 minutes to complete this module.
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1.3 Potential Risks
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This is Mrs. FH. She is 29 years old and healthy.
She is a G2 P0 at 28 weeks gestation.
She had a motor vehicle accident (MVA) today where she was a passenger wearing a
seat belt.
She has no obvious injuries other than bruising around the abdomen.
She arrived at the Assessment Room with a tender uterus.
What do you think are her risk factors, and what assessments are appropriate?
Click below to show/hide the risk factors.
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1.4 Assessment and Care
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What assessment parameters would you consider for Mrs FH on admission?
Click the button below to see which parameters you would assess.
Review and document Mrs. FH's assessment findings.
Go to Resources at the top of the screen to download and print the Admission Record.
Click on the Assessment Findings below and record the findings
on the Admission Record to practice documentation.
Recommended Parameters:
Vital Signs: BP, Temp, Resp, HR.
Assessment of amount of bleeding.
Uterine activity.
Fetal heart rate.
Fetal activity.
Abdominal palpation for tenderness.
Ultrasound to assess for fetal growth, fluid and placental location.
Pain.
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Assessment Findings:
BP: 110/70; Resp 16/minute
Temp: 37.1C; HR: 90/minute
No PV bleeding
No leaking amniotic fluid
Some irregular cramping, but no regular contractions
Normal preterm heart rate
Normal fetal activity
Ultrasound shows normal growth, fluid and a posterior placenta
Uterine pain: non-specific tenderness all over abdomen but not significant pain
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1.5 Communication
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Nurses
You prepare for communicating with the primary health care provider by completing the
SBAR tool:
 Situation
 Background
 Assessment
 Recommendation/ Request
You can download and complete the SBAR tool under Resources at the top of the screen.
Primary Care Providers
What would you expect to hear from a verbal report about the assessment in order to
consider decisions about care and follow up?
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1.6 Plan of Care
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Based on the assessment findings:
As a physician or midwife, what would you order?
As a nurse, what would you expect to be ordered?
How would you assess fetal well-being?
After you have considered the options for care, click on the Plan of Care button to view
a model answer.
Plan of Care:
Mrs. FH is admitted for observation.
Continuous EFM for 4 hours.
IV of Normal saline.
NPO
Bloodwork:
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 CBC
 Group & Screen

Coagulation studies

Kleihauer
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1.7 Assess for Fetal Well-being
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Click on the Tracing button to review the tracing.
How would you classify the tracing?
Refer to the BCW Fetal Health Card for help.
What is your assessment?
Include parameters for fetal health:
baseline, variability,
accelerations and decelerations.
Compare it to the assessment findings below.
What about the Plan of Care?
Assessment Findings:
Baseline - 140 bpm, variability is moderate, accelerations are present, and no
decelerations are present.
Gestational age appropriate criteria (under 32 weeks) include the accelerations being up
from baseline by 10 bpm and lasting for 10 secs.
Normal tracing
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Plan of Care:
NST for 4 hours
VS per protocol
Monitor PV bleeding
Assess uterine tenderness
Discharge if stable, after 4 hours
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1.8 Pregnancy At Term: Early Labour
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Mrs. FH is now at term gestation in early labour, and fetal growth has been normal. Her
pregnancy has been uncomplicated since the MVA at 28 weeks.
The placenta is fundal. She is experiencing moderate contractions q 3 min. lasting 45-60
seconds.
Cervical assessment is 5 cm dilated, 1 cm length.
She is using various coping techniques including walking, sitting in the shower, using the
birthing ball, and has family support.
What risk factors does Mrs. FH have?
Click below to show the risk factors.
Mrs FH's risk factors:
She has no risk factors
She is a low-risk woman in active labour
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1.9 Further Assessments
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What tools (Decision Support Tools) can the nurse use to determine the assessment
plan for maternal/fetal well-being?
Click the Tools button to view the actions to be taken.
How would you assess maternal/fetal well-being?
Click the Assessment button below to show the assessment recommendations.
Tools:
Use Decision Support Tool #2 Fetal Health Surveillance
Use Decision Support Tool #4 Evaluation of Progress of Labour/Dystocia
You can download these under Resources at the top of the screen.
Assessment Recommendations:
Download the Partogram under Resources
Maternal Assessment Parameters:
Vital signs
Cervical dilation
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Presence of PV loss
Coping with labour
Fetal Assessment Parameters:
Use IA and classify the auscultation
Assess fetal movement
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1.10 Intermittent Auscultation
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As part of your ongoing assessment you perform intermittent auscultation every 15
minutes, and this is what you hear:
What is your next step?
Click the button for a suggested response.
Next Step:
Listen with doptone after next fetal movement to assess for accelerations.
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1.11 Ongoing Care
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Mrs. FH is now at term gestation in early labour, and fetal growth has been normal. Her
pregnancy has been uncomplicated since the MVA at 28 weeks.
The placenta is fundal. She is experiencing moderate contractions q 3 min. lasting 45-60
seconds.
Cervical assessment is 5 cm dilated, 1 cm length.
She is using various coping techniques including walking, sitting in the shower, using the
birthing ball, and has family support.
What risk factors does Mrs. FH have?
Click below to show the risk factors.
Mrs FH's risk factors:
She has no risk factors
She is a low-risk woman in active labour
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1.12 Ongoing Care: Post-Epidural
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2 hours post-epidural, you review the partogram and see that Mrs. FH is still at 7-8 cm
dilated.
Review the Assessment Findings below and consider a Plan of Care.
Assessment Findings:
FH is normal with a baseline of 135 bpm and accelerations are present with fetal
movement.
Her labour has fallen off the expected level of progress.
The fetal heart rate is normal.
Plan of Care:
Consider artificial rupture of membranes.
Consider augmentation with oxytocin.
Continuous EFM if oxytocin infusing is being increased.
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1.13 Fetal Heart Tracing
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Click the tracing button to view the fetal heart rate tracing.
How do you classify this tracing?
What actions are appropriate?
Classification:
Baseline 125 bpm, changed from 135 bpm
Variability is moderate (6-25 bpm)
Complicated variable deceleration: single prolonged deceleration lasting >3min but
<10 min
No repetition of the deceleration
Classify as Abnormal.
Review overall clinical situation
Actions:
Continue EFM: observe for repetitive decelerations.
Frequent maternal position changes.
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Administer oxygen at 8L/min.
Perform fetal scalp stimulation.
Perform fetal scalp sampling: if pH is less than 7.25, repeat in 30 mins.
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1.14 Second Stage
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4 hours later, Mrs. FH is fully dilated and beginning to push. The presenting part is sp+1.
Click Tracing to review the EFM.
How often will you document the fetal heart rate on the partogram during this stage?
Systematically assess the tracing and classify.
Assessment:
Continue to monitor the fetal heart rate continuously.
Record the fetal heart rate on the partogram every 5 mins.
Classification:
The tracing is Normal.
This is a normal tracing, with occasional uncomplicated variable decelerations.
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1.15 Ongoing Care
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Mrs. FH has now been pushing for 1 hour.
Contractions q3 - 5 min. and the presenting part is now at spines +2.
In the past few minutes, you begin to see uncomplicated variables (≥3 in 10 mins).
How do you classify the fetal heart tracing?
What do you expect to happen next?
Classification:
Baseline is 150 bpm
Variability is minimal (0-5 bpm)
Accelerations are absent
There are ≥3 uncomplicated variables
Classify as Atypical.
Next Steps:
Labour is progressing, and it is not unusual to see uncomplicated variable decelerations
at this stage.
Institute intrauterine resuscitation- Oxygen at 8 L/min
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Change maternal position
Increase IV flow rate
Continue EFM.
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1.16 Communication
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What information are you communicating, as the primary care provider:
With the woman and her family?
With your colleagues?
With Mrs FH and family:
Identify that the fetal heart response is concerning, but can be expected at this stage of
labour. The team will continue to monitor the baby to ensure the safest outcome for
both mother and baby.
Some assistance to deliver the baby may be needed if the tracing does not improve, but
no intervention will be performed without her consent.
With colleagues:
Encourage maternal pushing as fetal head has descended to sp+2.
Alert the team of the fetal tracing and the possibility of an operative vaginal delivery ie:
forceps or vacuum extraction.
Communicate with Charge Nurse for assistance with coordination of plan of care.
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1.17 Spontaneous Delivery
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30 minutes later, Mrs FH has a spontaneous vaginal delivery of a 3200 gram baby girl.
Cord gases are drawn.
What would you expect the cord gas results to be given the tracing?
Interpretation:
The expected range for cord gases would be 7.21 to 7.25 with a base deficit of less than
5.
This would represent mild respiratory acidosis, which is transitory and will not result in
morbidity for the baby.
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1.18 Summary
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You have completed Module 4: Case Study!
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