Intra Partum Assessment Childbirth case study Zara PDF

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Childbirth Birth Process & Stages of Labor Intrapartum Nursing Assessment The Family in Childbirth: Needs and Care Zara ______________________________________________________________________________ In addition to the case study questions, students are expected to know the key terms for each chapter and be familiar with the various tables and assessment guides. Zara presents to Labor & Delivery Triage, stating she believes she is in labor. 1. What are the priority nursing assessments when a laboring woman arrives at the hospital? Observe demeanor, ask about labor & pregnancy, Onset, duration and frequency of contractions, Fetal movement, Vaginal bleeding, bloody show, mucous plug, ROM, Gestational age, Parity, Risk factors, Monitoring Fetal Heart Tones (FHTs) baseline rate, variability, accelerations, decelerations, Uterine activity: interval & duration, FHT response to contractions, Sterile Vaginal Exam (SVE), Dilatation, effacement, station, unless contraindicated. 2. Discuss appropriate teaching and other assessments that should take place once it is determined that the patient is in labor and is admitted to the birthing suite. Orient to room Cultural assessment Psychosocial assessment Plans for comfort measures Do not say “pain” or “are you planning to have an epidural?” 3. Describe the critical factors in labor Passenger: Fetus (size, presentation, molding, attitude, lie) Passageway: Pelvis & Presenting Part (cervix dilatability, vaginal canal distending ability) Powers: Physiologic forces Primary & Secondary (uterine contractions, abdominal muscles and bearing down efforts) Psyche: Psychosocial Considerations (causes and signs of labor) Prostaglandins cause contractions 4. How can the nurse help Zara distinguish between true labor and false labor? True Labor: Contractions regular, closer, stronger 30-60 sec Pain in the lower back that radiates to the front Contractions continue regardless of position Contractions intensify with ambulation Contractions do not decrease with rest or warm bath Progressive cervical dilation

To hospital when contractions are 5 min apart, last 45-60 sec., can’t talk through False Labor: Contractions weak, irregular, not getting stronger Pain localized in the front No lower back pain Contractions may stop or slow while walking or change position Contractions decrease with rest or warm bath Drink fluids and walk around. If decrease stay home Zara states that she prefers as little intervention as possible and plans to labor without medication for as long as she is able. Promotion of comfort and progression of labor 5. Discuss nursing measures that enhance the progress of labor and promote comfort during the first stage of labor Wash perineum Change under pads Fresh linen and gown Ambulation Position changes Cool washcloth Encourage to void Upright position Lollipop, ice chips Slippers or socks Hydrotherapy Relaxation exercises Breathing techniques Massage Relaxing music Birthing ball Analgesics, regional anesthetic blocks Zara walks around the nursing unit for an hour. She decides she needs a rest. Before she can return to bed, she feels a gush of fluid and puts on her call light. Explains to the nurse that she thinks her water has broken (SROM) 6. What is the priority nursing assessment following rupture of membranes? Priority: check fetal heart tones! SVE to rule out cord prolapse and determine progression of labor Note color and amount Yellow-green color may indicate fetal stress Notify care provider

The nurse carries out the appropriate assessments and performs a vaginal exam. Zara is 10 cm dilated, 100% effaced and the presenting part is at a +1 station (10/100/+1). Zara complains of rectal pressure and feeling like she needs to have a bowel movement. 7. What stage of labor has Zara just entered? Second stage of labor 8. What are appropriate nursing interventions during this stage? Sterile vaginal exams to assess fetal descent Mother: Blood pressure, pulse, respiration every 5–15 minute • Uterine contraction palpated continuously Fetus: FHR every 5 minutes Provide support and information about labor progress Assist with pushing Warm compresses Perineal massage Encourage rest between contractions Zara delivers a 4000 gram baby girl. She has a 4th degree perineal laceration that is repaired under local anesthesia. The baby is placed skin-to-skin with Zara. The nurse provides initial newborn care and assigns the Apgar score. Lactation is initiated within ten minutes of birth. 9. Define the four degrees of perineal lacerations/episiotomies 1st degree: epidermis 2nd degree: epidermis and muscle and fascia 3rd degree extends into anal sphincter 4th degree: extend into anterior rectal wall 10. Discuss nursing care and patient teaching following a 4th degree laceration Stool softeners Fluids Fiber Ambulation Don’t fight the urge Avoid rectal manipulations Enema Suppositories Thermometer 11. What stage of labor is Zara in immediately following the birth? Third stage of labor 12. Discuss the nursing care and promotion of comfort during the 4th stage of labor.

Assessments every 15 minutes for 1 hour, then every 30 min. until stable Uterine fundus for consistency Vaginal bleeding Perineum Bladder status Vital signs Skin to skin withing 5 minutes of birth or when newborn is stable. Encourage breastfeeding Provide perineal care & apply ice packs Heated blanket Warm drink Provide food Encourage rest Transfer to postpartum unit when stable Fetal Assessment during Labor 13. Discuss the physiologic basis for electronic fetal monitoring, and interpretation of FHR patterns Changes in the fetal heart rate pattern are influenced by: Fetal oxygenation status Autonomic nervous system Fetal acid/base balance

14. Identify the three categories of FHT patterns

15. Discuss interventions and rationales for Category III pattern Turn to left lateral position Reduce or d/c oxytocin Administer oxygen via non-rebreather face mask Increase IVF rate Notify the HCP Assess for underlying causes Provide reassurance Modify pushing if the 2nd stage Document interventions and responses Prepare for surgical birth if > 30 minutes...