Question

L&D Scenario

At 0830 hrs. - Leanne arrived by car to your unit, with her husband George and her mother Catherine. She states the membranes ruptured at 0800 hrs and is feeling uncomfortable

With contractions that started at 0500 hrs.

She is G1 P0 A0, Her LMP was April 2nd 2019. The Ultrasound and dates confirmed her.

EDD to be January 9th; making her 40+1 today.

Leanne last ate at 1800 hrs the night before and has been drinking clear fluids this morning.

Her blood group is A positive.

She is a healthy woman and has had a healthy pregnancy; taking vitamins only. Leanne plans to breastfeed.

Leanne has no allergies and has not been in contact with communicable diseases or had any recent hospitalization. GBS, HBsAG, HSV negative.

Leanne is having regular q 2-3 minute (3-4/10min) contractions that are strong on palpation with the uterus relaxing between. Her pad reveals clear amniotic fluid with scant mucous show.

Leanne states the baby has been moving; that she feels supported the way she is managing her labor even though the pain is intense. She describes her pain as a "6" on the pain scale.

She has been admitted directly to a birthing room.

0845 hrs - you perform a physical assessment -- Leopold's Maneuvers reveal a vertex

Presentation; Fundal Height 37cm; longitudinal lie, position LOA and the EFW 3600 gms. The FHR was 144 bpm .

The vaginal exam revealed a fully effaced cervix, 8cm dilated, station +1.

BP 110/70 Pulse 100 bpm and Respirations 24 Temperature 37.4C Urine Nil for protein and ketones.

After 2hrs she have regular q 2-3 minute (4-5/10min) contractions that are strong on palpation with the uterus relaxing between , with vaginal examination cervix, was 9cm dilated.

Vital signs are BP 115/75, p. 92 Respirations 24 Temperature 37C.

Questions:

- Develop nursing care plan ?

Answer 1

Labour is described as the process by which the foetus, placenta and membranes are expelled through the birth canal. Normal labour occurs when the foetus is born at term and presents by the vertex and the process is completed spontaneously by the natural unaided efforts of the mother.

The care plan varies according to which stage of labour the patient is in. Although the transition from first to the second stages of labour does not always have a clear distinction clinically but one can assume the patient is in second stage once the membrane is ruptured (as seen in this case scenario)or presenting part is appearing etc. But one could assume the patient is in the transition phase of the first stage since the cervical dialation is 8cm and the contractions are within an interval of 2-3 mintues.

The care plan

• The temperature and blood pressure of the patient should be evaluated every 4hrs. If a blood pressure of more than 130/80 mmHg is recorded the doctor should be notified; which is normal (115/75)in this case scenario.
• The pulse should be recorded every 15 minutes.Both the pulse and respiratory rate increases during contraction, hence shouldn't be evaluated during this time.
• The urine is examined for protein and ketones every two hours; which does not reveal any traces of either components in this case scenario.
• Oedema, pallor and other vital signs should be evaluated. Oedema may be due to pre-eclampsia and pallor in case of anemia. Both are absent in this case.
• Posture in labour : lateral position is recommended because Vena caval compression occurs during the first stage in some women and the supine hypotensive syndrome ensues when they lie on their backs. Provide the patient with a foam rubber wedge to maintain the lateral position.
• Diet during labour : solid food is withheld once labour is established; as the patient did in this case; but 5%glucose is given intake venously. Deprivation of glucose could lead to ketosis.
• Fluids : the patient should receive about 75ml of fluid per hour to avoid dehydration. Avoid fruit juices as it may induce vommiting, water or weak tea are the best options.
• Comfort and assistance : a nurse can add great comfort by attending to her personal toilet (as the bladder need to be emptied every 2 hours). Sometimes retention of urine can occur and in these cases plastic disposable catheters are used.

  :Clean clothing and changing of soiled bed linen could do a great deal in providing the patient with a better adjustment to the situation.

: cramp in the leg can be very distressing and the nurse can assist the patient to extend the leg and bring the toes towards the knee.

• labour should be allowed to occur naturally i.e. no artificial inducing agents/drugs should be given.
• No artificial intervention is required at the first stage since the patient is healthy with fundal heights within limits along with normal blood pressure, respiratory rate and pulse and the foetus exhibits normal heart rate, left occiput anterior (LOA) position with longitudinal lie and normal weight.
• During the second stage perineal cleaning should be done.
• After the patient enters the third stage of pregnancy and the placenta is delivered then is the time to administer oxytocin intramuscularly to promote uterine contractions.
• Upon delivery of the newborn the mother should be allowed to breastfeed the child which gives way for bonding.