Labor and Birth Case Study Sally Rogers is a 25-year-old G1P0000 at 37 weeks gestation presenting to triage for suspected labor. Sally reports coming in to be seen because she has been feeling her abdomen tightening every 3-4 minutes with mild back pain and noticed some bleeding for two days. She states her mucous plug fell out 12 hours prior. She has been having increased nausea with episodes of vomiting. She has been having more energy than usual and has been working on cleaning and preparing the room for the baby. 1. What additional questions would be important to ask Sally? When is your expected due date, Is this your first pregnancy? Have you had any complications during this pregnancy? Do you have a Dr that is been following your pregnancy? 2. What is Sally likely experiencing? Early signs of labor. 1. What type of labor is Sally experiencing? Latent phase of labor 2. What recommendations would you provide? Walk, showing her breathing techniques to promote relaxation, different positions to find comfort The nurse begins her triage and places Sally on the external fetal monitor. 1. What questions would be appropriate to gain a thorough prenatal history? Have you had any complications with this pregnancy, do you have any infections, do you have any another medical problem, do you use any illegal drugs? 2. What initial assessments would be important for the triage nurse to perform prior to contacting the provider? Assess the fetal heart rate, cervical dilatation, and effacement. 3. What additional prenatal information is necessary for the triage nurse to obtain? Do you have any allergies, do you have any family history or premature deliveries, do you, what medications are you currently taking? Sally’s initial vital signs are 129/85mmHg, HR 95, Temp 98.6F, SpO2 98%, RR 22. Pain score is 7/10 during contractions. Sally continues to grimace and scream during each contraction. Her Cervical exam: 3cm/50/-1. The baby is vertex. Review the following fetal monitoring tracing: 1. 2. 3. 4. What is Sally’s stage and phase of labor? Latent phase What action should the nurse take next? Early term What fetal heart rate pattern is being exhibited on the tracing? Bradycardia Analyze the following tracing: a. What is the FHR baseline? 100 b. Variability - Moderate c. Accelerations present? No d. Decelerations present? No e. NICHD category? III After performing the initial fetal intrauterine resuscitation interventions, the fetal heart rate returned to baseline. Review the following tracing. The nurse previously contacted the provider to report the fetal bradycardia. He ordered to admit the patient for labor and place on continuous monitoring. 1. 2. 3. 4. 5. What is the current FHR baseline? 150 What is the uterine activity? Normal frequency Is uterine tachysystole present? No What is the variability? Minimal Are accelerations present? No What interventions would the nurse have performed after contacting the provider to aid in improving the previous fetal bradycardia? Reposition to limit cord compression and improve blood pressure The triage nurse is providing report to the labor and delivery nurse who will assume care. 1. What information would be necessary for the triage nurse to provide in transfer of care report? Fetal heart rate, Cervical dilatation, effacement, and station, pain level. 2. What admission assessment data would be important for the receiving nurse to obtain from the patient to provide the most appropriate family centered care? . Her Cervical exam: 3cm/50/-1. The baby is vertex, allergies, level if pain. 3. What assessments would be appropriate for the nurse to perform and discuss during this current phase of labor? Vaginal check to see how many centimeters her cervix is dilated What phase of labor is the patient currently in? Latent face 4. What psychosocial data would you expect to see her to exhibit during this phase of labor? Agitation, anxiety, distress, fear. 5. What medications would the nurse anticipate would be ordered for labor? Oxytocin Prenatal History G1P0000 PMH: Asthma, chronic HTN Social hx: marijuana, occasional alcohol use, unemployed, lives with parents Family hx: HTN, preterm birth, stroke, CVA Prenatal Labs: A-, HIV neg, RPR neg, Chlamydia positive, Gonorrhea negative, HSV negative, GBS positive, Rubella immune Immunizations: Hep B, Varicella, Tdap, Influenza, COVID-19 Labs WBC- 25,000 H/H- 10/30 Platelets- 250 Medications Prenatal vitamins 1 tab PO daily Folic acid 400mcg PO daily Docusate sodium 100mg PO daily Labetalol 200mg PO daily 12 hours have passed during Sally’s induction and she has now progressed in labor. She is currently unmedicated for labor. Her most recent cervical exam revealed: 7cm/90/0. She states she feels that she sometimes feels the urge to push but it is not constant. 1. Sally asks what she should expect during labor. She desires to understand what changes will occur with her body in labor? What physiologic changes will she undergo during labor?? a. Cardiovascular increase cardiac output expended blood volume and reduced systemic vascular resistance and blood pressure. b. Respiratory increase muscular work and oxygen consumption increases c. GI Gastric motility and food absorption decrease, which may increase the risk of nausea and vomiting during the transition stage of labor d. GU feelings like to have a bowel movement e. Neurological headache, dizziness, pressure f. Musculoskeletal Muscular aches and cramps occur as a result of stress on the musculoskeletal system. 2. What stage and phase of labor is Sally currently in? Active 3. Why would she have an urge to push and bear down without being fully dilated? Contractions. 4. What risks do she have if she begins to push with her urge currently? Tiredness, swelling of the cervix which this leads to a delayed delivery, tearing of the vaginal wall. 5. What does her fetal monitoring strip read? a. Baseline 130 b. Variability Moderate c. Accelerations Absent d. Decelerations Early decelerations e. Category I 6. What are fetal physiologic responses to labor? Gradual increase in physiological stress 7. What intervention(s) would be necessary at this time? relaxation and paced breathing techniques that they learned to cope with the contractions. 8. How would the nurse evaluate that the interventions were effective or not effective? By looking at patient how she responds to pain. Sally has been reporting increased pelvic pressure and rectal pressure. She was recently started on Oxytocin to augment her contractions since her uterine activity had decreased. Her membranes were ruptured previously and an intrauterine pressure catheter (IUPC) and FSE was placed for fetal assessment. Her most recent cervical exam reveals: 9cm/100/2. She has increased bloody show and feeling rectal pressure. She expressed to the nurse that she is in extreme pain and desires pain management. What options would be most appropriate for the nurse to prescribe at this point? 1. Nonpharmacologic options breathing techniques 2. Sally desires to know all her pharmacologic options that would be available for her at this time. Epidural 3. What information on the fetal monitoring tracing would be most concerning? How would the nurse intervene? Late decelerations 4. How would the nurse evaluate that the interventions were effective or not effective? The increase in the number of contractions. An hour later, Sally calls out to notify her nurse that she is experiencing a significant increase in rectal pressure and discomfort. The nurse comes to the bedside to assess and determines Sally’s cervical exam is 10cm/100%/3. 1. What stage of labor has Sally progressed to? Transitioning 2. What is important during this stage? That she is ready to push and delivery. 3. What fetal monitoring and uterine changes occur at this time? Tachysystole, normal heart rate, minimal variations and a late deceleration. 4. What assessments would the nurse observe and perform during this stage? Fetal heart rate. 5. What education would be beneficial to provide Sally during this period? To breath in through her nose and out her mouth. 6. What additional information would be appropriate to ask regarding the impending birth and care of fetus? The nurse calls the delivery team to the room to prepare for the impending birth. 1. What actions should the nurse take during the second stage to prepare for the transition to the third stage of labor? Telling the patient to push when she feels like pushing 2. What interventions would the nurse perform during the birth. Monitor the baby heart rate and the mothers’ vital signs 3. What teaching topics would be beneficial for this client preparing to give to keep calm and perform breathing techniques to avoid hyperventilation, keep pushing as you feel like pushing 4. What is important for the nurse to perform to provide immediate care to the newborn dry the newborn to avoid heat loss through evaporation and situate the baby to cry. Sally begins to push and successfully delivers a healthy 8lb 6oz newborn girl. At 1 minute, the newborn HR was >100, respirations 60 breaths/min, was limp, grimace, and cyanotic. By 5 minutes, the newborn HR was >100, respirations 55breaths, tight flexion, vigorous cry, with acrocyanosis. 1. What would the APGARS be at 1 and 5 minutes? 6 - 9 2. What medications would be administered to the newborn? Erythromycin ointment for the eyes and vitamin K. As the provider cuts the cord, the newborn is placed skin to skin on Sally to promote breastfeeding. Sally is not done giving birth. 1. What stage of labor is she current in after delivering her newborn? 3 2. The provider is at the bedside performing uterine massage to assist in the expulsion of the placenta. What signs would be present to indicate the placenta is prepared for expulsion from the vagina? Uterus contacts and rises, the umbilical cord lengthens, and a gush of blood occurs. 3. What are the changes that occur in the uterus prior to expulsion of the placenta? The uterus contracts and rises, the umbilical cord suddenly lengthens 4. What should the nurse anticipate regarding bleeding in the immediate postpartum client? The client will have bleeding during the first few hours. What is normal v. abnormal bleeding in a vaginal birth? Blood cloths is a normal finding in the first hours, a soft uterus is abnormal finding. The provider reports that Sally had an estimated blood loss of 400mL. She has a second-degree perineal laceration that was repaired. No episiotomy and no retain fragments of placenta noted. 1. What interventions are important to perform in the immediate postpartum period massage the fundus. 2. What medications would be used during this period for standard care? Oxytocin to prevent hemorrhage and contract the uterus. 3. What medications would be given if the patient loss an excessive volume of blood? Oxytocin 4. How would you describe her laceration? Tear of the muscle. What care is important and why? No surgical repair is needed, apply ice for comfort. 5. After expulsion of the placenta, what stage of labor is Sally currently in? 4 Sally is bonding with her new baby girl. She has completed her care for the initial two hours post delivery and is transferred to postpartum unit. Which stage of labor is she in? 4 The nurse is performing a shift assessment on Sally and notes the following information: Vitals: BP 130/80mmHg, HR 50, RR 20, Temp 99.0, SpO2 98%. Fundus: +1 on left and boggy. Lochia: moderate pink tinged. No clots noted. Last bowel movement today. Passing gas. Breast firm and edematous with colostrum. No redness or warmth. Extremities: +1 pedal edema bilaterally. +2 pulses bilaterally. Lungs clear bilaterally, unlabored. S1, S2 noted. Hypoactive bowel sounds. She is experiencing some perineal discomfort from labor. Sally is displaying irritability, slight mood swings, tearful, and fatigued. She has slept about 18 hours in the last 3 days. She does not have any support systems with her to assist her with the baby while the hospital. The newborn has been awaking every 1.5-2 hours to feed for 30-45 minutes per session. She was having some mild nipple pain and cracking after the feeds with the newborn displaying signs of hunger after each feed. Discuss the assessment performed, what data is normal versus abnormal? What is the rationale for your responses. 1. What assessments, interventions, and evaluations would be appropriate to perform? 2. What physiological changes are expect to occur in the postpartum period? a. Reproductive the cervix remains soft after birth. The vagina contracts and begins to return to the size before pregnancy b. Cardiovascular cardiac output will return to normal two weeks after delivery. c. Urinary retention can damage detrusor muscle and parasympathetic nerves d. Respiratory the pressure decreases in the diaphragm and reduction in pulmonary blood volume e. GI increase flatulence increase, gas and bloating often become a problem f. Musculoskeletal stress on the axial skeleton, pelvic girdle and genital tract, joint disruption, and septic arthritis. g. Integumentary striae gravidarum, thinning or regression of the hairline h. Endocrine estrogen and progesterone levels drop dramatically which can contribute to the “baby blues” i. Ovulation and return of menstruation irregular periods, woman who are breastfeeding are more likely to notice irregular periods, as the hormones that support breastfeeding can cause the body to delay ovulation or ovulate infrequently 3. She desires to breastfeed, what should she expect regarding potential lactation? Her breast can become engorged and tender. What breastfeeding specific education would you provide? She needs to breastfeed her baby from both breasts, she needs to feed the baby on demand and recognize signs of hunger and feed her baby 8 to 12 times in 24 hours. 4. She reports having sore and cracked nipples, what recommendations could you provide? Put some milk in the nipple and let them air dry. 5. On day 3 postpartum, Sally notices that her breasts are enlarged, swollen, and painful upon waking. What is she experiencing? Engorgement Is it preventable? Yes How could she relieve this discomfort? Feed baby on demand from both breasts and take a hot shower before breastfeeding to soften the breast. 6. What nutritional changes would you teacher her since she is breastfeeding? Avoid spicy foods, avoid caffein, alcohol because that will pass the baby through her milk. 7. Are there any contraindications to breastfeeding? Mothers with HIV and galactosemia 8. What is baby friendly care and how would you provide this to her and the family? Promoting breast feeding to promote bounding with her baby 9. Is she at risk for postpartum mood disorders? Yes If so, what mood disorder and why? Baby blues due to the decrease of estrogen and progesterone levels. 10. Are there variables specific to this patient that can affect her maternal role attachment and attainment? Her addictions, and been a single mother, if she develops depression can also be a factor. Sally and the newborn baby girl are ready for discharge home today. 1. What discharge instructions are important to discuss prior to discharge? Discuss early signs of complications and what to do if they occur. 2. Are there any additional tests needed? PKU 3. What is necessary to administer to Sally prior to discharge and why? Rhogam 4. What follow-ups are important for Sally upon discharge home to ensure that she is transitioning well to motherhood? Referral to a primary care provider, and a referral to a social worker. What potential challenges do she face at discharge? Post-partum blues and depression.
