Initial assessment
The patient is a 28-year-old Hispanic woman, G3P1. Her last pregnancy was healthy. According to the cervix contractions and per vaginam measurements, the patient is in the first stage of labor in a latent phase (Durham & Chapman, 2019). Fetal position is the most common, and the patient can have a vaginal delivery. According to vital signs, the patient is anxious and excited. Before pregnancy, her BMI was 24,2, and her current BMI is 28,3. During pregnancy, the patient has not gained enough weight.
The nurse’s first actions are to set up electronic fetal monitoring, begin the Friedman graph, and assess fetal heart rate-uterine contraction (FHR and UC’s) every 1 hour. It is also essential to identify the presence of bloody show and rupture of membrane (ROM), encourage the patient to relax, encourage void every two hours, and help find the position of comfort. The nurse can ask if the patient has pain and how strong it is. If the pain is sharp, non-pharmacological pain strategies should be initiated. The nurse can assist the patient in diversional activities and encourage control of breathing, position changing, and ambulation.
To assess the fetal biological system, the nurse does FHR every 1 hour, Leopold maneuvers, and SVE examination. To create a proper social atmosphere for the patient, the nurse identifies her support person (the husband) and assists both of them in their role. The nurse includes them both in patient teaching and care and encourages the husband to stay with the patient.
After SROM
FHR becomes category II: fetus rate decreases less than on 15 beats and stays in the normal borders, and prolonged decelerations are detected. The priority of a nurse is to assess fetal well-being. It is essential to deliver in 24 hours because the rupture of the membrane increases the risk of intrapartum infection (Durham & Chapman, 2019). The characteristics of the fluids were normal, with no signs of blood and other pathological substances. The SVE identifies softening of the cervix walls but still latent labor phase by all the measurements.
The patient should be kept at the hospital for complete monitoring and bed rest. Nursing management is to prevent any complications of the condition, as well as infection. Evaluating the membrane status can help with further tactics. Afterward, the number of SVEs should be minimized to prevent infection (Durham & Chapman, 2019). The next step is to obtain smear specimens from the vagina and rectum to test for streptococci.
Teaching. The nurse should also provide the patient with family education and encourage her and her husband to prepare for labor and birth. Explaining the treatments that will possibly be needed to prepare the patient psychologically.
Nursing diagnosis: Risk for infection due to loss of protective barrier. Moderate labor pain. Expected outcome: the patient will have no signs of any infection, such as increased temperature, changes in heart rate, different vaginal smell, or colorful thick vaginal drainage. According to the nurse’s pain management plan, the patient will have decreased pain using non-pharmacological pain management (breathing, position changing, walking).
Non-pharmacological pain management. Using patterned breathing allows focusing and improving the labor process. Explain to the patient that, due to active breathings, the oxygen accesses the baby better and staying well-hydrated helps her condition. Movement and comfortable position search can help identify the posture where the pain decreases. The nurse can help find the position and make sure it is safe. Method of focus and distraction can help visualize the active phase of labor and its successful outcome (Durham & Chapman, 2019). Such techniques can help reduce fear and anxiety and make the patient in a better mood.
2 A.M
Assessment. The patient entered the active phase of the first labor stage. Nursing priorities. The nurse informs the patient of the progress of her labor to get in contact with her and give her motivation to encourage her to be continuously active to maximize the effect of uterine contractions. Additionally, the nurse monitors FH, helps find positions of comfort, and monitors maternal vital signs and fetal vital signs depending on the doctor’s order. The nurse also helps with the needs of the patients if she needs to keep the bed clean and dry, putting on a forehead compressor with cold tissue and other comfort requirements. It is important to remind the patient to void as the full bladder can interrupt or slower the labor process.
Nursing diagnosis: acute labor pain. Expected outcome: the patient has decreased pain and can focus on productive contractions and being focused. Interventions: position of comfort, non-pharmacological strategies, breathing, helping with needs, and reminding of voiding.
04.10 A.M
Appropriate interventions are monitoring the contractions and FHR every 15-30 minutes, maternal vital signs every 1 hour, assessing pain, asking the patient of its degree and location, considering epidural anesthesia, offer oral fluids. Explain to the patient her progress and promote her comfort measures as well as non-pharmacologic strategies. Assist with the elimination of vomiting, explain that it is a variant of the norm, explain that the uterus and intestine might contract together, and that is why she had a regurgitation. The nurse prepares for delivery.
06.30 A.M
Priorities. The patient entered the second labor stage and can push now harder along with uterus contractions. FHR indicates the lowered heart rate of the fetus. Bradycardia of the fetus needs monitoring of the FHR every 5-15 minutes (or after every contraction) and suppose umbilical cord entanglement. Ask the patient to focus on breathing and pushing, assist in a comfortable position in pushing, and encourage upright positions. Rationale. The lowered rate and indirect hypoxia signs are frequent situations in the second stage of labor.
Nursing diagnosis: bradycardia of the fetus with possible cord entanglement. Outcomes: effective pushes with fetal descendants. Interventions: assisting support with relaxation breathing, identifying changes in tension, keeping the patient relaxed, reassuring the patient’s condition, and pharmacological pain management.
07.30 A.M
Help focus the patient for the final pushes. Update on the progress and encourage her husband to support her breathing and pushing. Prepare episiotomy if necessary. Encourage rest between contractions by breathing with the patient and using therapeutic touch. Rationale. Episiotomy might not be needed; however, it has to be prepared to prevent possible ruptures of vaginal walls.
08.15 A.M
The final period of the second stage. Control the fetal heart rate after each contraction, prevent the rupture of the vaginal walls with the help of hands, and prepare for episiotomy. If the loop is identified, lessen the tension around the newborn. The nurse should include lateral episiotomy if needed (second pregnancy might not be needed). Afterward, place the newborn on the mother’s abdomen skin-to-skin, awaiting delivery of the placenta. It is essential to inspect the placenta after delivery so that it fully comes out with no pieces left inside the uterus. Suturing the episiotomy under anesthesia and monitoring the patient’s vital signs. Finally, labor summary, delivery summary for mother and baby, infant information, assessment, and documentation. The nurse stays with the woman and her family, answers possible questions, and guides her with further tactics and the delivery process.
Reference
Durham, R., & Chapman, L. (2019). Maternal-Newborn Nursing: The critical components of nursing care (3rd ed.). F.A. Davis Company.