Date: (Present date)
CASE SCENARIO #2
Ms. Judy Halo Diaz , a 25 yo, G2P1 patient, AOG, 39 5/7wks came in the hospital
together with her parents at 11:00 PM, experiencing moderate to strong uterine contraction for
about 3x in 10 min time, uterine contractions started at 5pm as verbalized by the patient. Upon
examination, IE revealed 5 cm dilated, station -1, Cephalic in labor, 100 % effaced, intact BOW,
Initial V/S : BP- 110/60 mmHg, T- 37 ℃, HR- 75 bpm, RR- 20, BPM, FHT- RLQ 158 bpm.
Admitted in the labor room for monitoring. Administered IVF D5LR 1Liter x 8 hours.
Labor monitoring were as follows: At 11:30 PM the uterus contracts at about 52 secs,
moderate to strong intensity, 11:33 PM another uterine contractions occurred lasting about 65
seconds, strong in intensity. Ms. Judy complained again of another strong uterine contractions at
11:35 PM that lasts about 60 seconds followed by another strong uterine contractions lasted
about 58 seconds at 11:38 PM and contracts again after 2 min lasted for 65 seconds, strong
uterine contractions.
At 1:00 AM, she was examined by DR nurse and revealed 8 cms dilated, station 0, intact
BOW. Uterine contractions about 4-5x in 10 min, V/S- BP- 130/70 mmHg, T- 37.0 ℃, HR- 100
bpm, RR- 24 BPM, FHT- 150/min. bloody show becomes more prominent.
At 3:00 AM, the client groans in pain and said she feels like defecating and pushing! She
was then examined by DR nurse and revealed cervix fully dilated, station +2, she had
Spontaneous rupture of membranes right after examination., clear amniotic fluid. FHT- 156/min,
BP- 130/80 mmHg, T- 37.4℃, HR- 96 bpm, RR- 24 BPM.
At around 3:05 AM, the client shouted, “its coming”, upon checking the head of the baby
is already crowning, she was then transferred to the delivery table, positioned in lithotomy by the
assist nurse and prepared for delivery…..
Patient Judy had a normal spontaneous vaginal delivery to a live term baby girl at 3:10
AM with an APGAR score of 7, 9. Injected 10 units Oxytocin at 3:11 AM after excluding
another baby. Placenta was delivered completely at 3:15 AM. EINC performed. Initial NB V/S
taken- T- 36.8℃, HR- 168/min, RR- 65/min. Anthropometric measurements were: Wt- 3.9 kg,
BL- 52 cm, HC- 34 cm, CC- 32cm, AC- 29 cm. Newborn therapeutics were given and was
explained to the mother. Second NB VS done after 15 min, T-36.5 ℃, 155 beats/min, RR- 59
breaths/min, (to continue monitoring V/S every 15 min for 2 hrs in real setting )
The mother had 4th degree laceration with right mediolateral episiotomy. Episiorrhaphy
done under local anesthesia. Estimated blood loss (EBL) is about 500 cc., with contracted uterus.
She had perineal swelling and hematoma. Postpartum V/S- BP- 110/70, T- 37.5℃, HR- 100 bpm
and RR 20 BPM. Succeeding V/S were normal except for her body temp, 37.8℃ - 38℃. She
was referred to the AP and was advised to have TSB. (tepid sponge bath)
Endorsed to Maternity ward at 5:30 AM with IVF #1 D5LR 1L + 10 units Oxytocin
regulated at 32 gtts/min infusing well on the right hand to consume if without profuse bleeding.
Uterus well contracted. Latest VS- T- 37.3℃, BP- 120/70 mmHg, HR- 89 bpm, RR- 20 BPM.
Check voiding 4-6 hours after delivery and refer if unable to void. Encourage to increase fluid
intake and early ambulation if not contraindicated. Instruct proper perineal care and perineal pad
change. Watch out for any signs of bleeding and refer accordingly.
To start Medications:
1. Amoxicillin 500 mg 1 cap x 8hrs for 7 days
2. Mefenamic Acid 500 mg 1cap q 6 hrs x24 hrs then as needed for Pain.
3. Ferrous Sulfate 1 tab OD
4. Senokot 2 tablets at night
5. Methergine 1 tablet 3x a day for 3 days only.
Treatment:
a. Apply ice pack on the perineum for 24 hours with 30 min resting time every after each
application.
b. To start perilight after 24 hours post-delivery. Perilight 15 min 2x a day
ASSIST NURSE: Endorse the client to the Maternity area (Head nurse- Clinical Instructor/or to
the incoming Student Assist nurse) regarding the client status, contraptions (IVF), medications
(with medicine cards) and other instructions.
ACTUAL NURSE: To endorse labor monitoring to the DR Nurse ( Clinical Instructor or to the
incoming Student actual nurse) the first 10 minutes of labor monitoring. Prepare DR instruments
according to use.
NEWBORN NURSE: Accomplish and complete Newborn record admission and endorse to the
NICU nurse (Clinical Instructor or to the incoming Student Newborn care nurse)