Maternity Clinical Amelia Sung Documentation PDF

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Maternity Case 3: Amelia Sung Documentation Assignments 1. Document the fetal status and the progression of Ms. Sung’s labor from the time you took over care of Ms. Sung until the provider takes her to the delivery room. ●

Ms. Sungs cervical exam was at 2 cm dilation, 80% effaced at -1 station with fetus in vertex position. At 0100 hours, dilation was 4 cm, 100% effaced, still at -1 station and fetus in vertex position. She received an epidural shortly after that, and 1 hour later, her membranes ruptured; the fluid was clear.

2. Document the essential events related to the time of birth, including the activities and interventions from the time of crowning to the complete expulsion of the fetus. ● ● ● ●

0820 The fetus head started crowning. Encouraged the patient to push. 0837 The fetus head was delivered. 0900 The fetus head retracted. 0905 Placed patient in McRobert’s position per provider’s orders. 0910 Applied suprapubic pressure per provider’s order. 0920 the fetus shoulders were delivered.

3. Document the application of suprapubic pressure and the response and outcomes. ●

Supapubic pressure performed to dislodge the shoulder that is being obstructed by pubic bone. Intervention was successful and the fetus was delivered

4. Document your communications with the neonatal intensive care unit (NICU) about the impending birth. ●

0900 NICU was called. The patient is in birthing room 2. Patient pushed and head was delivered at 0837. Turtles sign positive. Estimated fetal weight 4,000 grams. The fetal heart rate is 90 bpm with decreased variability. McRoberts maneuver performed. Need NICU team for possible neonatal asphyxia or fetal injury.

From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.

Maternity Case 3: Amelia Sung Guided Reflection Questions

Opening Questions How did the simulated experience of Amelia Sung’s case make you feel? ●

This experience helped me understand what I would have to do in this type of scenario if it were to happen in an actual clinical setting. It made me feel like I would be more prepared to help assist with a patient experiencing a shoulder dystocia.

Describe the actions you felt went well in this scenario. ●

I feel like it went well when I made sure the patient got 10L of O2 via a nonrebreathing mask when I noticed the fetal heart rate was decreasing. I also felt like I did well when I called the charge nurse to make sure they were informed on the situation and could come assist.

Scenario Analysis Questions1 EBP What risk factors specific to shoulder dystocia were identified in Amelia Sung’s case? ● ● ● ● ●

The patient had uncontrolled maternal gestational diabetes. A prolonged second stage of labor. The patient's weight gain was greater than 50lbs. Patient’s height is 5ft 3in. Estimated fetal weight 8lb 13 oz.

PCC/I Prioritize your nursing actions for Amelia Sung based on your assessment. ● ● ● ● ● ● ● ● ●

Administer 10L of O2 via a nonrebreathing mask. Take the patient’s vitals - including a focus assessment on the patient’s respiratory system. Check the patient's deep tendon reflexes. Perform vaginal assessment to see where the fetus is located, noted crowning. Preparing for delivery by grabbing the delivery table and bassinet. Call the provider to come in and notice a positive turtle sign. Notified charge nurse and NICU. Get step stool. Get patient in McRobert’s position, and apply suprapubic pressure.

1 The Scenario Analysis Questions are correlated to the Quality and Safety Education for Nurses (QSEN) competencies: Patient-Centered Care (PCC), Teamwork and Collaboration (T&C), Evidence-Based Practice (EBP), Quality Improvement (QI), Safety (S), and Informatics (I). Find more information at: http://qsen.org/

From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.

EBP

List potential problems for Amelia Sung and her baby related to the shoulder dystocia. ●

For the patient, after a shoulder dystocia, the patient has increased risk for bladder trauma, vaginal laceration, and postpartum hemorrhage. For the baby, increased risk for erb’s palsy, asphyxia, and a fractured clavicle. T&C

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List the interprofessional health care team that should be involved in Amelia Sung’s case.

The provider, NICU team, and the charge nurse. S/QI/I Consider what points might be included in a safety checklist for shoulder dystocia.

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Understanding the risk factors, having proper tools ready in case it is suspected, and contacting the charge nurse and NICU in advance.

Concluding Questions Reflecting on Amelia Sung’s case, were there any actions you would do differently? Explain. ●

No, I believe that after the first try at the stimulation I did everything correctly.

Describe how you would apply the knowledge and skills that you obtained in Amelia Sung’s case to an actual patient care situation. ●

I would know to call the charge nurse and the NICU team to the delivery room to have extra support.

From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health....