Question

Case Studies

Essentials of Maternity, Newborn, and Women's Health Nursing

Chapter 14: Nursing Management During Labor and Birth

1. Desiree, a 28-year-old G2P1, is admitted to the labor and birth unit. Her birth plan indicates that she is planning natural childbirth without pharmacological interventions. She has attended childbirth education classes. Desiree is considered low risk based on her personal and family health history and physical exam. Her pregnancy has progressed without complications. She is approximately 38 weeks pregnant. Vaginal assessment reveals cervical dilation at 10 cm, 100% effaced, and +1 station. Position of the fetus is LOA. The external fetal monitor indicates a reassuring fetal heart rate at 130 beats per minute. Maternal status is stable. (Learning Objectives 1, 2, 6, and 9)

Based on the vaginal assessment, identify the stage of labor and appropriate nursing interventions for this stage of labor.

Explain how the nurse determined that the external fetal monitor would be appropriate for Desiree. What factors would necessitate a change to internal fetal monitoring during labor?

Desiree says, “I’m not sure I can cope with the pain much longer.” How would you respond, considering her birth plan, stage of labor, and assessment data?

2. Emily, a 26-year-old G3P2, has been in labor for 5 hours and is 7 cm, 90% effaced and +2 station. She has external fetal monitoring in place, which reveals a baseline fetal heart rate of 120 bpm, minimal variability, and occasional variable decelerations. Suddenly, as a contraction is beginning to subside, the fetal heart rate drops to a low of 80 bpm and has a slow return to the baseline 1 minute after the contraction has ended. (Learning Objectives 4 and 5)

A. What is happening to Emily’s baby at this point in time? What does this mean?

B. What role do you, as the nurse, play regarding fetal assessment and what interventions do you need to implement/recommend at this point in time?

Answer 1

Question 1 Answers:

Stage of Labor:

Since the cervical dilatation is full or complete with 10 centimeters, she is in the second stage of labor. 100% effaced cervix means the cervix is effaced completely and became paper thin. The second stage may last from 15 - 30 mts. to several hours. The station is zero when the fetal head is in level with the ischial spine of the pelvis. The fetal station +2 means the baby descended already 2 cms.

Nursing Interventions:

Help the client with breathing and pushing technique. Encourage her to hold her breath and push along with the contractions. Ask her the preferred position for pushing and help her to change positions if she wants. Continue monitoring the fetal heart rates and the length, frequency, and strength of contractions. Prepare for episiotomy procedure if necessary. Also, prepare for vacuum extraction or forceps delivery, in case the progress of contraction and pushing slows down or stops or the baby shows any signs of distress. Pitocin also should be kept ready to strengthen the contractions.

The nurse determines that the external fetal heart rate monitoring is appropriate because of the reassuring heart rate of 130 beats/mt. and the client is considered a low-risk patient because of her personal and family history and physical examination reports. Internal fetal monitoring is necessary when closer surveillance is needed or when the reading from the external monitoring is not good since it may be affected by the movements. Obesity of the mother, position of the baby, polyhydramnios etc. may affect the external fetal heart monitoring. There are no such indications in the given scenario.

The nurse can reassure the client that the baby will be born without pharmacological interventions if she continues to push along with contractions some more time. Since there is no sign of any risks or fetal distress as per the assessment data, natural childbirth will be a most rewarding experience for her psychological satisfaction. Encourage her to hold on for a bit more.