Labor and Delivery Case Study PDF

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Labor and Delivery LEARNING OBJECTIVES 1. Interpret the data given and determine the phase and stage of labor the client is experiencing.

2. Discuss the psychological and physiological characteristics of all phases of the first stage of labor.

3. Analyze available data and determine actual or potential nursing diagnoses and/or collaborative problems appropriate to the first stage of labor.

4.

Identify appropriate nursing interventions relative to each phase / stage of labor.

5.

Describe priority nursing actions during labor.

6.

Discuss commonly used obstetric medications and their nursing implications.

CRITICAL THINKING QUESTIONS 1. Tabitha has been “leaking water” for several hours, earlier in the day she had an amniotomy. She is 34 weeks pregnant and is at a -3 station. You place the patient on the fetal monitor and notice the baby is having variable decels. What do you suspect is happening? What are the immediate nursing interventions? Give rationales for each. The “leaking water” could be due her previous amniotomy or even a premature rupture of her amniotic sac. Variable decels are a sign of umbilical cord compression which could be caused by maternal position with cord between fetus and maternal pelvis, or a knot, short cord, or the cord wrapped around the fetus. The immediate interventions would be the following: -

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Change the mother’s position side to side or knee to chest, this can relieve the compression. Administer oxygen at 8 to 10L/min by nonrebreather face mask, this helps with increasing the oxygen supply to the fetus. Notify the physician since this is a medical emergency Assist with vaginal or speculum exam to assess for cord prolapse to fix the compression on the umbilical cord. Assist with amnioinfusion, if ordered, this relieves the cord compression by restoring the amniotic fluid volume to normal.

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Assist with birth if the pattern cannot be corrected, because this is an emergency situation.

2. Mariah has been in labor for eight hours. You check her External Fetal Monitor strip and notice this pattern. What is your next step? This is showing early deceleration, which are caused by uterine contractions, vaginal examination, fundal pressure, and placement of internal mode of monitoring. All of these things cause fetal head compression. No interventions are needed since this is benign, just continue to monitor.

3. Michelle is a G2 P1 at 35 week’s gestation. She came to the ER complaining of abdominal pain. She is experiencing moderate vaginal bleeding. Her vital signs are: B/P 90/52, HR 115 bpm. Fetal heart tones are 160-170 bpm with minimal variability and repetitive late decels. What do you suspect is happening? What actions will you take? Discuss all rationales. The patient is experiencing abruptio placentae, which is a premature separation of the placenta from the implantation site. This explains the abdominal pain and vaginal bleeding. The late decelerations of the fetal heart tones indicate decreased blood flow to the fetus. A large bore catheter should be obtained for fluid replacement to raise the patient’s blood pressure. She should also be placed in a lateral position to prevent pressure on the vena cava. Her vital signs and the fetal heart rate should be monitored for any changes. An ultrasound will be done to determine the extent of the abruption and the patient should be prepared for a cesarean section.

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4. Susan is 42 weeks’ gestation. Her pregnancy has been uneventful except for a diagnosis of gestational diabetes. She is 10 cm dilated and 100% effaced. She begins to push, the fetal head comes out and goes back in. What is this called? What do you suspect is happening? What steps would you take to deliver this baby? How may this affect the baby and why? This is called shoulder dystocia. This is a condition where the head is born, but the anterior shoulder can not pass under the pubic arch. As a nurse you should stay calm, immediately call for additional assistance. You will also help the woman into positions that may facilitate birth of the shoulders. One of the steps taken to deliver the baby would be attempting the McRoberts maneuver where the woman’s legs are apart with her knees on her abdomen. This causes the sacrum to straighten, the symphysis pubis to rotate toward the mother’s head, and the angle of pelvic inclination is decreased freeing the shoulder. This is the preferred method when the woman is receiving epidural anesthesia. You will want to assess the newborn for clavicle or humerus fractures, brachial plexus injuries, and asphyxia.

5. Describe the first stage and phase(s) of the labor process including cervical dilation, expected duration or each and maternal behavior and nursing care during each stage. Select a nursing diagnosis for each stage. The first stage of labor is the Latent Phase. This phase lasts from the onset of contractions to effacement and dilation of the cervix, 0 - 3cm, contractions are every 5 to 30 minutes. During this phase the mother may be talkative and eager, becoming tired, restless, and anxious as labor intensifies and contractions become stronger. Interventions: encourage mother and partner to participate in care, assist with comfort measures, change positions, ambulate. Keep the mother and partner informed of progress, offer fluids and ice chips. The other phases are the active phase with cervical dilation 4 - 7 cm, with moderate to strong contractions coming 3 - 5 minutes apart. The mother may become more serious, doubtful of pain medication, more apprehensive, fatigue, flushed and difficulty following directions. Interventions: encourage maintenance of effective breathing patterns, provide a quiet environment, keep mother and partner informed of progress, promote comfort, offer ice chips. The transition phase with cervical dilation 8 - 10 cm, with very strong contractions coming 2 -3 minutes apart lasting the longest 45-90 seconds. The 3

mother may show frustration, describe pain as severe, fear a loss of control, irritable, doubt if she can continue, she may also have nausea and vomiting. Interventions: encourage rest between contractions, wake mother at beginning of contraction so she can begin breathing pattern, provide privacy, offer ice chips and ointment for dry lips. NANDA: Acute pain r/t labor contractions during initial placental separation as evidenced by uterine tenderness and pain high in the fundus.

6. Lynn delivers a baby girl, 7 lb. 12 oz. vaginally at 6 pm. After one hour your assessment findings reveal: pulse 98, resp. 24, B/P 95/60, temp 99.5, fundus is palpated at U-2, firm & midline; lochia is rubra, heavy and bright red. Perineum is intact without swelling, discoloration or drainage. IV of LR with 20 Units of Pitocin is infusing in the right arm @ 125 mL/hr. She has been assisted to the bathroom to void and is back in bed breastfeeding the baby. She complains of menstrual-like cramps. Describe the problems she is most likely experiencing and the nursing actions you will take. Discuss the rationale for each action. The mother is experiencing after pains, which are caused by uterine contractions. Breastfeeding and Pitocin usually intensify these afterpains because both stimulate uterine contractions. Pitocin is mainly given to prevent postpartum hemorrhage. Relaxation and breathing techniques can relieve some of the pain. Medications, such as ibuprofen, can be given after consulting with the physician beforehand.

7. The nurse assesses the FHR. The EFM reveals the following strip. Analyze this strip for FH baseline, variability, periodic changes, & contractions pattern. Discuss the significance of this FHR pattern and the immediate nursing actions in order of priority with rationales.

FH baseline: 170 Variability: Minimal Patient also has one late deceleration and two disruptions in the monitor due to maternal movement. Late deceleration could be due to uteroplacental insufficiency. This could be associated with fetal hypoxemia, acidemia, and low Apgar scores. Some interventions are changing the maternal to a lateral position to reduce vena cava pressure, elevate maternal legs to correct hypotension, increase the rate of IV infusion and administer oxygen at 8 to 10 L per minute by nonrebreather face mask. 4

8. Your patient is in active labor. An epidural anesthetic is ordered. Describe the care for the patient before, during and after administration of an epidural and the complications associated with them. Are there any contraindications that the nurse should be aware of? Prior to block: - Assist primary health care provider or anesthesia care provider with explaining procedure and obtaining informed consent. - Assess VS, hydration, labor progress, FHR and pattern. - Start IV line and infuse bolus of fluid, if ordered. - Labs: hematocrit or hemoglobin - Assess level of pain using a 1-10 scale - Assist woman in voiding - If the patient has a tattoo, avoid initiating the procedure at that site During initiation of block: - Assist woman into proper position. - Verbally guide through procedure. - Document vital signs and meds given. - Monitor maternal and fetal VS - Have O2 and suction available. Monitor for signs and symptoms of anesthetic toxicity as test dose is given. While block is in effect: - Continued monitoring of maternal and fetal VS. 5

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Assess woman’s level of pain Monitor bladder distention and help her void Encourage position changes from one side to the other every hour Promote safety by keeping guardrails up, call light within reach, instruct her not to get out of bed without help. Keep insertion side clean and dry Monitor for anesthetic SE

As the block is wearing off: - Assess for return of sensory and motor function. - Monitor vital signs, bladder distention. - Promote safety. - Keep insertion site clean and dry Complications -

Hypotension Local anesthetic toxicity Fever Urinary retention Pruritus Limited movement Longer second stage labor Increased use of oxytocin Increased likelihood of forceps

Contraindications - Active or anticipated serious maternal hemorrhage - Maternal hypotension - Coagulopathy - Infection - increased ICP - Allergy - Some cardiac conditions 9. Your patient has just arrived to Labor and Delivery. She is 38 weeks’ gestation and she states that her “water just broke.” You place her on the fetal monitor and see this strip. Interpret the strip. What is your next nursing action?

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Baseline of 150, minimal variability, with accelerations since it has gone above the baseline and lasted more than 15 seconds. This is normal so no nursing interventions are required for the fetus, however with the mother stating her water just broke and accelerations, preparation for delivery should be started.

10. Complete drug studies for these medications a. Hemabate (4 pts) b. Oxytocin (3 pts) c. Nubain (3 pts) Drug Generic name: Carboprost tromethamine

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Dosage & Frequency Usual Dosage 250 mcg IM or intrauterine injection every q1590 min up to

Route IM or intrauterine

Classification Oxytoxic hormone

Action & Purpose of Drug

Action: Contraction of uterus

Side Effects & Major nursing implications Mom: Headache, nausea and vomiting, fever, chills, tachycardia, hypertension,

eight doses Brand name:

Purpose:

Hemabate

Management of postpartum Fetal/Newborn: hemorrhage Implications: Continue to monitor vaginal bleeding and uterine tone.

Drug Generic name: Oxytocin

Brand name: Pitocin

Dosage & Frequency Usual Dosage 10 to 20 units/L up to 80 units/L diluted in lactated Ringer’s solution or normal saline at 125 to 200 milliunits/min IV; or 10 to 20 units IM

Route Classification IV or IM

Action & Purpose of Drug

Oxytocic hormone Action: Contraction of uterus; decreases bleeding

Purpose: Oxytocin is used primarily for labor induction and augmentation; it is also used to control postpartum bleeding.

Side Effects & Major nursing implications Mom: Uterine tachysystole, placental abruption, uterine rupture, unplanned cesarean birth caused by abnormal FHR and patterns, postpartum hemorrhage, infection, and death from water intoxication (nausea and vomiting)

Fetal/Newborn: hypoxemia and acidosis, eventually

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resulting in abnormal FHR and patterns.

Implications: Continue to monitor vaginal bleeding and uterine tone.

Drug Generic name: Nalbuphine Hydrochloride

Brand name: Nubain

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Dosage & Route Classification Frequency Usual IV or Opioid Dosage IM agonistantagonist IV: 10 mg analgesic every 3 hours as needed IM: 10 mg every 3 hours as needed

Action & Purpose of Drug

Side Effects & Major nursing implications

Action: Mixed agonistantagonist analgesic that stimulates kappa opioid receptors and blocks or weakly stimulates mu opioid receptors, resulting in good analgesia but with less respiratory depression and nausea and vomiting when compared with opioid agonist analgesics. Nalbuphine’s analgesic effect is equivalent to morphine,

Mom: Sedation, drowsiness, nausea, vomiting, dizziness, respiratory depression,

Fetal/Newborn: temporary absent or minimal fetal heart rate (FHR) variability Implications: May precipitate withdrawal symptoms in opioid-dependent women and their newborns. Assess maternal vital

on a milligramto-milligram basis. Produces a maternal ceiling effect on pain relief and respiratory depression after 30 mg of the drug has been administered. Duration of action is 2 to 4 hours when given intravenously and 4 to 6 hours when given intramuscularly.

Purpose: Moderate to severe labor pain and postoperative pain after cesarean birth

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signs, degree of pain, FHR, and uterine activity before and after administration. Observe for maternal respiratory depression, notifying primary health care provider if maternal respirations are ≤12 breaths/minute. Encourage voiding every 2 hours, and palpate for bladder distention. If birth occurs within 1 to 4 hours of dose administration, observe newborn for respiratory depression. Implement safety measures as appropriate, including use of side rails and assistance with ambulation. Continue use of nonpharmacologic pain relief measures....