DE GUZMAN, CAMERON JOSH B.
APRIL 26, 2021
2BSN-B RLENCM109
POST-TERM LABOR
CASE SCENARIO:
Juanita Juarez 23-year-old G1 P0 nullipara woman at 42 weeks gestation presents to the emergency room in questionable labor. She is concerned
that she has not yet gone into labor and verbalized “dinudugo po ako pero hindi pa naman nasakit ung tyan ko”. The nurse assess the mother by
inspecting, and by checking the baby position and presentation using Leopold’s Maneuver. The nurse also places the patient on an electronic fetal
monitor and is concerned that there is a non-reassuring fetal heart rate (FHR) tracing. She decides that Juanita should be further evaluated in the
labor and delivery suite. The nurse is concerned with her assessment of the FHR pattern and decides to place an IV and notifies a resident who is in
the Operating Room completing a C-section. After completion of the C-section, the resident evaluates Juanita and decides to perform an ultrasound.
The ultrasound is performed more than 3 hours after the patient’s arrival at the hospital. Based on the ultrasound it shows that the baby is having
trouble getting enough oxygen and the baby is in distress and the FHR pattern show slow to none fetal heart tone, an emergency C-section is
performed for a live born male.
Vital signs taken as follows: T: 37, P: 90, R: 17, BP: 120/80
Leopold’s Maneuver: breech presentation
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIONS RATIONALE EVALUATIONS
Independent
Subjective: Risk for Risk for The nurse will [Link] baseline [Link] to evaluate fetal status in The baby’s fetal
The patient complications of Complications of manage and fetal heart rate and before and after labor. status have
verbalized non-reassuring Non-reassuring minimize evaluate as Category I improved and w
“dinudugo po fetal status in Fetal Status episodes of (Normal) if: 2. This lets your healthcare provider able to have
ako pero hindi relation to none -Describes a fetus non-reassuring • Baseline rate is 110 see how your baby is doing. Your enough oxygen
pa naman reassuring/ soft- experiencing or at fetal status. to 160 bpm healthcare provider may do fetal heart
nasakit ung none fetal heart high risk to • Regular rhythm monitoring during late pregnancy and
tyan ko” tone experience a (with auscultation) labor.
disruption of the • Presence of
Objective: physiologic moderate baseline 3. The staff nurse is the one person
T: 37 exchange of variability (normal who has current and detailed
P: 90 nutrients, oxygen, fetal rate has a fine information on the patient's condition.
R: 17 and metabolites irregularity of 6 to 25
BP: 120/80 bpm) 4. This position decreases occlusion of
FHT: non- • Presence or absence the inferior vena cava by displacing
reassuring/ of accelerations the uterus, promoting venous return
soft to none • Early decelerations to the heart.
(transient slowing of
Ultrasound: fetal heart rate with [Link] ensures constant monitoring
the baby is compression of the and also may help reduce the
having trouble contraction causing mother’s anxiety.
getting enough parasympathetic
oxygen stimulation), present 6. This increases oxygen delivery to
or absent the fetus.
Leopold’s • Absent late
Maneuver: decelerations 7. Intravenous fluids (usually
breech shortened to 'IV' fluids) are liquids
presentation 2. Monitor for non- given to replace water, sugar and salt
reassuring fetal heart that you might need if you are ill or
rate or rhythm, having an operation, and can't eat or
drink as you would normally. IV fluids
[Link] the physician are given straight into a vein through a
or certified nurse drip.
midwife of the
situation and your 8. Augmenting amniotic fluid volume
assessment findings may decrease or eliminate problems
associated with a severe reduction or
[Link] the mother absence of amniotic fluid, such as
on her left side severe variable decelerations during
labor.
[Link] with the
mother and partner, 9. To evaluate fetal pH and metabolic
provide information, Status. A non-acidotic fetus will
and give them respond with an acceleration of 15
opportunities to share bpm in amplitude or more for a
concerns and fears. duration of 15 seconds or more, which
usually reflects a pH of 7.2 or greater
Dependent and a normoxic central nervous
[Link] oxygen system (Lyndon & Ali, 2009).
by face mask at a flow
rate of 10 L per
minute, according to
protocol
[Link] with a bolus
of IV fluid.
8. Consider
amnioinfusion
according to
protocol/policy.
9. Consider fetal scalp
blood sample
according to
protocol/policy
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIONS RATIONALE EVALUATIONS
Independent
Subjective: Risk for Risk for The nurse will [Link] the uterine [Link] uterine atony, a boggy or The mother was
The patient Complications of Complications of manage and fundus every 15 relaxed uterus will not control able to managed
verbalized Postpartum Postpartum minimize minutes for the first bleeding by compression of the and lessen any
“dinudugo po Hemorrhage in Hemorrhage postpartum hour postpartum; uterine muscle fibers. further
ako pero hindi relation with -Describes a woman bleeding. every 30 minutes the complication of
pa naman prolonged/ post who is experiencing second hour 2. Massage stimulates the uterine postpartum
nasakit ung term pregnancy or is at high risk to postpartum; every muscle to contract. hemorrhage
tyan ko” experience acute hour for third and
blood loss greater fourth hour, and every 3. Careful vital sign monitoring
Objective: than 500 mL after shift thereafter; provides accurate evaluation of
T: 37 vaginal birth or evaluate. hemodynamic status.
P: 90 greater than 1,000 • Height (normally
R: 17 mL after cesarean should be at the level 4. Continuous seepage of blood with a
BP: 120/80 birth within the first of the umbilicus after firm uterus can indicate cervical or
FHT: non- 24 hours delivery) vaginal lacerations. Bleeding after the
reassuring/ postpartum • Size (when first 24 hours can indicate retained
soft to none (primary contracted, should be placental fragments or subinvolution.
hemorrhage) or about the size of a
Ultrasound: occurring after 24 large grapefruit) [Link] visual blood loss in cubic
the baby is hours and before • Consistency (should centimeters of blood stained on a pad
having trouble the 6th week feel firm) in a certain period of time, or weigh
getting enough postpartum saturated pads, linen protectors, or
oxygen (secondary 2. If the uterus is linen (1 g 5 1 mL; Gilbert, 2011).
hemorrhage). relaxed or relaxing,
Leopold’s massage it with firm 6. This increases oxygen delivery to
Maneuver: but gentle circular the fetus.
breech strokes until it
presentation contracts. 7. A decrease in the hemoglobin value
of 1.0 to 1.5 g per dL and a four-point
[Link] blood drop in hematocrit indicate a blood
pressure and pulse loss of 450 to 500 mL.
every 15 minutes for 1
hour, then every 30 8. By inserting a Foley catheter, you
minutes for the next are gaining access to the bladder and
hour, and then once its contents. Thus enabling you to
every hour until the drain bladder contents, decompress
mother’s condition the bladder, obtain a specimen, and
stabilizes. Continue to introduce a passage into the GU tract.
monitor as needed. This will allow you to treat urinary
retention, and bladder outlet
[Link] perineal obstruction.
blood loss.
[Link] and
estimate blood loss
Dependent
[Link] oxygen
by face mask at a flow
rate of 10 L per
minute, according to
protocol
[Link]
laboratory/diagnostic
studies (CBC, type &
crossmatch,
coagulation profile).
Report a decrease to
the physician or
certified nurse
midwife.
8. Insert Foley
catheter to monitor
urinary output
according to
protocol/policy.
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIONS RATIONALE EVALUATIONS
Independent
Subjective: Risk for Risk for The nurse will 1. Monitor fluid status; 1. Early detection of fluid deficit The mother hav
The patient Complications of Complications of manage and evaluate: enables interventions to prevent successful C-
verbalized Bleeding in Bleeding minimize • Intake (parenteral shock. section was able
“dinudugo po relation with -Describes a person bleeding and oral) managed and
ako pero hindi bloody vaginal experiencing or at episodes. • Output and other 2. Careful monitoring allows early minimized any
pa naman discharge and high risk to losses (urine, detection of complications. bleeding episod
nasakit ung emergency C- experience a drainage, and
tyan ko” section decrease in blood vomiting), nasogastric 3. This measure promotes optimal
volume tube renal tissue perfusion.
Objective:
T: 37 2. Monitor the 4. This helps decrease tissue demands
P: 90 surgical site for for oxygen
R: 17 bleeding, dehiscence,
BP: 120/80 and evisceration. 5. High anxiety increases metabolic
FHT: non- demands for oxygen
reassuring/ 3. Contact physician or
soft to none advanced practice 6. Diminished blood volume causes
nurse with assessment decreased circulating oxygen levels.
Ultrasound: data that may indicate
the baby is bleeding and to 7. Protocols aim to increase peripheral
having trouble replace fluid losses at resistance and elevate blood pressure.
getting enough a rate sufficient to
oxygen maintain urine output
>0.5 mL/kg/hour (e.g.,
Leopold’s saline or Ringer’s
Maneuver: lactate).
breech
presentation 4. Minimize client’s
movement and
activity.
5. Provide
reassurance, simple
explanations, and
emotional support to
help reduce anxiety.
Dependent
6. Administer oxygen
as ordered.
7. Insert an IV line; use
a large-bore catheter
if blood or large
volume fluid
replacement is
anticipated.
