Case study:
Mrs. Cuaresma, is a 28 year old G3P2 who was admitted at term at 9:30 PM. She said she had been having contractions at 8 to 10 minutes
... [Show More] interval since 5 PM. They lasted 30 seconds. She also stated that she had been having “a lot of false labor” and hoped that this was “the real thing”. Her membranes were intact. Mrs. Cuaremsa’s temperature, pulse and respirations were normal and her blood pressure is 120/80. The FHT is 135 bpm and regular. The nurse examine Mrs. Cuaresma’s and found that the baby’s head is at +2 station and the cervix is 5cm dilated and 80% effaced. She reported her findings to the doctor and she ordered Demerol 50 mg with Phenergan 25 mg to be given intravenously when needed.
Questions:
1. Do you think Mrs. Cuaresma is in false labor? Give reasons for you answer
No, because false labor begins and remains irregular, do not increase in duration, frequency or intensity, and it does not achieve cervical dilation. However, according to the case of Mrs. Cuaresma, she have been having a contractions at 8-10 minutes interval that last 30 seconds. Which means that Mrs. Cuaresma is in the first stage of labor specifically in the active phase.
Moreover, internal examination shows that the baby’s head is at +2 station meaning birth is about to happen and the 5cm cervical dilation and 80% effacement are a progressive change in the cervix which is a sign of true labor.
Therefore, Mrs. Cuaresma is not in false labor rather, she is already experiencing a signs of true labor due to the contractions that occur regularly and due to the progressive change in the cervix.
2. As Mrs. Cuaresma is getting into her bed, her membranes ruptured. What is the first thing that you would do after this occurs, why?
Check if the Bag of Water is clear because if it’s green in color, this may indicate sign of fetal distress. Presence of meconium staining if the fetal is in vertex position may indicate fetal anoxia and meconium aspiration. In fetal anoxia, this is due to inadequate oxygenation of the mother while meconium aspiration occur when newborn breathes a mixture of meconium and amniotic fluid.
Therefore, it is important to know the color of the ruptured membrane in order to notify the attending physician and be able to provide immediate care to the mother and baby.
3. After her membranes ruptured, her contractions began coming every 4 minutes and lasted 45 to 55 seconds. They are moderately strong. Why is it important for Mrs. Cuaresma to relax during her contractions? How can you help her to relax?
Relaxation during contraction can help the client to prevent and lessen the stress and tension feeling that she is having during contraction. It also serves as a distraction technique because, while concentrating on relaxing, a woman cannot concentrate on pain. In addition to conscious relaxation, having a woman shift position or find the position in labor that is most comfortable for her can be helpful.
Since Mrs. Cuaresma is having a 4 minute contraction lasting 45-55 seconds and is moderately strong in intensity, then this means that she is in active phase. And ways to help her relax is through non-pharmalogical pain management such as providing quiet environment, hydrotherapy, comforting music, performing comfort measures like back rubs, and I may also encourage level 2 breathing pattern. And pharmalogical pain management ordered by the doctor such as the 50 mg Demerol with 25 mg Phenergan.
4. When do you think Mrs. Cuaresma should be given medication ordered by the order?
Ordered Demerol 50 mg with Phenergan 25 mg to be given intravenously is needed to be administered when moderate to severe pain is intolerable. Reason for administering this drugs is that this will make the patient calm which helps in preventing anxiety feeling that may cause elevation of the blood pressure.
a. What safety measures should be taken at the time medication is given?
At the time medication is given, make sure that the client is not allergic to the medication, and FHT is normal wherein if the client express concern regarding the medication then there is the need to stop and do not administer medication. Moreover, safety precautions for patients receiving IV opioid medication includes frequently monitor respiratory rate, sedation level, and oxygen saturation level or exhaled carbon dioxide to decrease the risk of adverse reactions associated with IV opioid use. If adverse reactions occur, respond promptly to prevent treatment delays which could put the baby and the mother at risk.
b. What observations should be made after it is given? Why?
After the medication is given, observe if the medication led the patient to desired effect wherein patient will be able to show signs of alleviated discomfort or labor. Observe if the client had relaxed and calmed after the administration of the drug because this indicates that the drug is working unto the client. Moreover, there is also a need to observe for any signs and symptoms of adverse reactions to the drug such as increase in blood pressure, decrease in oxygen saturation, decreased fetal heart rate, and increase in respiratory rate and pulse rate because this may indicate that there is something wrong with that client that could put risk unto the mother and the child.
c. What observations would you report to the doctor?
Observations that is needed to report to the doctor is when there is an adverse reaction such as decreased fetal heart rate, skin rashes, elevated blood pressure and respiratory rate that could cause threat to the life of both the child and mother. There is a need to report if reactions were shown or noted in order to provide care and treatment to the client immediately. Observing and monitoring for the decrease and increase fetal heart rate is the top priority to be reported to the doctor as this may indicate danger signs of fetal distress.
5. How would you know that Mrs. Cuaresma has entered the transition phase?
If internal vaginal examination shows 8-10 cervical dilation and if labor contraction is every 2-3 minutes lasting 60-90 seconds with strong intensity then this indicates that Mrs. Cuaresma, has entered the transition phase. Additionally, transition phase is described when the patient will report intense discomfort accompanied by nausea and vomiting. Observable data include patient being irritable and sensitive is also an indication of transition phase.
All in all, knowing is the client has entered the transition phase of stage 1 of labor is through internal examination, palpation of the abdomen, and assessment date which are the subjective data from the patient and objective data by the senses of the nurse.
6. A vaginal exam revealed that Mrs. Cuaresma is complete and +3
a. What should be the nursing intervention at this time?
+3 fetal station indicates that the baby is below the ischial spine and presenting part of the baby can be seen. This +3 also mean crowning of the baby’s presentation and birth is about to happen. At this time, nursing intervention is done such as assessing temp., pulse, respirations, blood preassure, and fetal heart rate. Additional nursing intervention is to teach client effective breathing technique which can be an effective way to reduce labor pain.
7. What is ritgen’s manuever?
a. Is it important to do ritgen’s manuever during delivery?
Ritgen's maneuver denotes extracting the fetal head, using one hand to pull the fetal chin from between the maternal anus and the coccyx, and the other on the fetal occiput to control speed of delivery. Therefore, ritgen's maneuver denotes extracting the fetal head, using one hand to pull the fetal chin from between the maternal anus and the coccyx, and the other on the fetal occiput to control speed of delivery.
The doctor gave her a pudendal block and did a midline episiotomy. At 11:05 PM, Mrs Cuaresma gave birth to a 8 lbs, 5 oz baby boy in the LOA position. The nurse puts medicine in the baby’s eyes and placed an identifying bracelet on his right wrist and ankle. A matching bracelet was placed on the mother’s wrist. The baby was shown to his mother and then taken to the nursery. At 11:30 PM the placenta was expelled.
8. Why is the medicine put in the baby’s eyes?
Newborns receive erythromycin eye ointment after birth to prevent pink eye in the first month of life, also called ophthalmia neonatorum (ON). Also, this is to protect babies from getting bacterial eye infections that can occur during birth. Untreated, these infections can cause serious problems including blindness.
9. Why is it important to put identification on the baby in the delivery room?
Newborn identification and registration is an important step after the immediate newborn care to avoid switching of babies or kidnapping in the healthcare facility. Baby identification includes the spelling of names and dates. Putting the identification bands provide safety and security to the baby and also to the mother whereas, the identification band will provide connection to the mother and to the baby.
10. What care should Mrs. Cuaresma receive before she is transferred to the recovery room, why?
Before Mrs. Cuaresma is transferred to the recovery room, perineal care should first be given to her. Clean the perineum of the mother and check how heavy the bleeding of the mother because heavy bleeding may indicate postpartum hemorrhage. There is a need to examine for the perineum, vagina, and vulva for tears. And lastly, make the mother comfortable before transfer to the recovery room in order to provide comfort and may help Mrs. Cuaresma in having an adequate rest. [Show Less]