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Normal Pregnancy and Pain Management Case Study

CONCEPT: REPRODUCTION NUR 113


Time: 1!"
Heather Morris, RN, has just arrived to work her evening shift in Labor &
Delivery. This is her
th
year as an RN in the unit. !hile waiting for re"ort on
her "atient she reviews the #hart, revealing the following$

Melanie %auer, ad&itted ' hours ago, is a '()year)old gravida ' "ara *)()*)*
&arried wo&an whose e+"e#ted date of delivery is today. Her ,rst "renatal
visit was at *- weeks and she had *( visits total. Melanie.s lab work in#ludes$
He&oglobin$ *-g/dL
%lood ty"e$ 0 negative
1DRL$ non)rea#tive
2rinalysis$ nor&al
Rubella titer$ *$*(
He"atitis % s#reen 3Hbs0g4$ negative
H51 s#reen$ negative
6a" s&ear$ Negative
7igni,#ant infor&ation$
Melanie.s "re)"regnan#y weight was *8( "ounds, weight gain was
8(9.
Her baseline blood "ressure was **(/:8, %6.s re&ained **()*-(/:8);(
throughout her "regnan#y.
Her routine urine sa&"les were nor&al and her #hart reveals nor&al
fetal growth throughout her "regnan#y.
7he had - ultrasounds and did not want to know the se+ of her baby.
0 <uad &arker s#reen at *: weeks was within nor&al li&its.
Melanie had a glu#ose s#reen at -8 weeks with a "las&a glu#ose level
of **( &g/dL.
Her =rou" % stre" s#reen at ': weeks was "ositive.
7he re&ained healthy and a#tive and &edi#ations in#luded only
"renatal vita&ins daily.
7he did re"ort "roble&s with #onsti"ation and he&orrhoids during her
"regnan#y.
5n re"ort, Heather learns that at her last e+a& * hour ago$
Melanie.s #ervi+ was dilated to : #& and >(? e@a#ed, at a Aero
station.
The baby.s "osition is RB0.
7"ontaneous ru"ture of &e&branes o##urred at ho&e : hours ago,
Cuid was #lear.
Melanie is having strong #ontra#tions every - &inutes, lasting :(
se#onds.
Detal heart tones are *8()*( with good variability.
1ital signs$ HR E F(, RR E -(, Te&" E FF.>, %6 E *--/;-.
7he has an 51 of LR in her right ar& that is saline lo#ked.
7he and her husband are using their breathing te#hni<ues and &anaging the
#ontra#tions well. They are really "leased that they did not have to be
indu#ed again like last ti&e. Melanie ho"es to have a natural #hildbirth
without the use of drugs, whi#h she also a##o&"lished with her ,rst delivery.
7he did relate that her #ontra#tions see& stronger this ti&e and she &ay be
rethinking that de#ision.
Melanie.s husband Mark is with her in labor, they have taken #hildbirth
"re"aration #lasses. Mark was also "resent for the vaginal delivery of their
son 7i&on who was born - years ago. The Gerti,ed Nurse Midwife will be
attending the delivery though she is not #urrently on the unit. 0s the day
shift RN leaves for ho&e, Heather "lans her evening and thinks$ H5 anti#i"ate
a routine delivery within the ne+t few hours.I
I# you $ere caring #or Melanie% &ere are some 'uestions to (onder
!hat s#reenings were done antenatally and whyJwhat other
s#reenings &ight have been doneK
0re #onsti"ation and he&orrhoids in "regnan#y nor&alK !hyK
!hat are other dis#o&forts of "regnan#yK
!hat is the signi,#an#e of the #lient.s Rh negative statusK
5s her weight gain a""ro"riate for her "regnan#yK
!hat are the i&"li#ations of &edi#ations/drug use/ s&oking use in
"regnan#y 3in#luding "renatal vita&ins and foli# a#id4K
!hat the &eaning of ='6*(**K
!hat is the signi,#an#e and e+"e#ted &anage&ent of her grou" %
stre" "ositive statusK
!hat stage of labor is she in and how does the baby.s "osition a@e#t
the "rogression of laborK
How does a "atient stay hydrated in laborK
!hat are the i&"li#ations of a full bowel or bladder in laborK
!hat breathing te#hni<ues would be &ost advantageous for the
"atient to use in labor in ea#h stageK
How #an the nurse su""ort the fa&ily unitK
!hat non)"har&a#ologi#al #o&fort &easures #an the nurse "rovideK
How does the nurse "re"are for a routine deliveryK
How is the laboring "rogress des#ribed and what is is the e+"e#ted
#ourse of laborK
5f Melanie does #hange her &ind regarding &edi#ation in labor, what
&ight you suggest and what are the i&"li#ations for the fetusK
!hat are standards of #are related to fetal &onitoring and
do#u&entationK
How would you do#u&ent her labor "rogressK
!hat would #on#ern you on the fetal &onitor tra#ingK
Time: 1)3*
0s Heather "re"ares to &eet her "atient and do an assess&ent, Mark runs
out of the labor roo& and is #learly u"set and an+ious. He yells$ HLou need
to hurry, she wants so&ething for "ain and she says she feels like "ushing.
The baby.s heart rate is slowing down and 5 #an hear itMI Heather knows that
the nurse &idwife is at ho&e at least -( &inutes fro& the hos"ital. Heather
re#alls that at the last e+a& one hour ago, Melanie was only : #enti&eters
dilated and only >(? e@a#ed. 7he had "lanned to ask Melanie how long her
labor was with her son, but is now #on#erned that this labor &ay be
"rogressing &ore <ui#kly. 7he is #on#erned that Mark is an+ious and worried
and #learly wants her attention.
!hat should the nurse do ,rstK
!hat would you in#lude in your 7%0R #o&&uni#ation with the
"roviderK
!hat is the infor&ation a#<uired during a vaginal e+a&K
How do you assess fetal status and what would you e+"e#t as nor&alK
!hat is the signi,#an#e of feeling "ushyK
!hat does Heather need to know about "ain &anage&ent at this "oint
in laborK
!hat is the best res"onse to Mark to hel" hi& &anage his an+ieties
about the babyK
Time: +1**
The &idwife, Gara, has been on the unit for one hour. 7he ordered Nubain
*( &g 51 whi#h was given when she arrived. Melanie is now #o&"letely
dilated and she has been "ushing for ten &inutes. The baby is #rowning. The
DHT.s are dro""ing down to F( b"& fro& a *8(b"& baseline with ea#h
#ontra#tion. Mark #ontinues to su""ort her and see&s to be less an+ious now
that Gara is here. He has <uestions regarding whether an e"isioto&y #ould
hel" labor "rogress faster, and is this a&ount of bleeding nor&alK He
#ontinues to e+"ress #on#ern about the fetal heart rate dro""ing.
!hat e@e#t is Nubain going to have on the fetus and how will this
a@e#t nursing #are of the infantK
!hat are indi#ations for an e"isioto&y and nursing i&"li#ations for
"atient tea#hingK
!hat is the esti&ated blood loss for a nor&al vaginal deliveryK
How will blood loss i&"a#t he&oglobin, he&ato#rit and vital signsK
How and why do DHT.s #hange during a nor&al deliveryK

Time: +11*
Melanie delivers a baby boy who is i&&ediately "la#ed on her abdo&en.
His 0"gars are > at one &inute and F at ,ve &inutes. Gara waits *( &inutes
for the "la#enta to be delivered inta#t. 7haron "ersuades Mark to #ut the
#ord and he has tears in his eyes as he and Melanie &arvel over their new
son. The baby is awake and Melanie wants to know if it is too soon to
breastfeed. They begin dis#ussing the need to have their baby #ir#u&#ised
and ask you for your thoughts on the &atter.
!hat is involved in the i&&ediate #are of the newbornK
How should the nurse res"ond to Melanie.s <uestion about
breastfeedingK
!hat #an be e+"e#ted of the infant.s behavior over the ne+t few
hoursK
!hat assess&ents should the nurse do for a newborn and what
tea#hing is #riti#alK
!hat is involved in Melanie.s "ost)"artu& #he#ks and what are nor&al
,ndingsK
!hat tea#hing will Melanie need before she is dis#hargedK
How should the nurse res"ond to Melanie and Mark.s <uestions about
the ne#essity for #ir#u&#isionK
!hat infor&ation should the nurse give Melanie regarding follow)u"
#are for herself and the babyK