High-Risk Labor and Delivery Case Study Comprehensive Nursing Essay Example

High-Risk Labor and Delivery Case Study Comprehensive Nursing Essay Example

It is my second shift as a labor and delivery nurse, and the assigned case study involves Patient Mallory, a 42-year-old single African American attorney whom I admitted to care of pre-term labor at 32 weeks’ gestation yesterday. Her treatment comprised of magnesium sulfate and betamethasone. Tonight, when I arrived for my shift commencing at 7:00 p.m. the patient, remained on magnesium sulfate although her contractions and regular and by 3: 20 am has a spontaneous rupture of membranes (SROM) for clear fluid. By 4:00 a.m., the magnesium sulfate and a normal spontaneous vaginal birth were expected due to the advanced pre-term labor with her cervix at 5cm /90%/ +1. The following hour finds Mallory contracting every 2 to 3 minutes and coping well with the uterine contractions and has Alison, her sister, at the patient’s bedside providing labor support. The fetal heart rate (FHR) is 140s and has average variability, occasional accelerations, and decelerations. Major highlights of the nurse’s caring are highlighted in the five subsections that follow and appropriate responses outlined.(High-Risk Labor and Delivery Case Study Comprehensive Nursing Essay Example)

1. At 5:15 a.m., Mallory feels the urge to have a bowel movement, and you do an SVE. Her vaginal exam reveals that she is 10 cm/100%/+1.

• Who needs to be notified of your significant assessment findings?

The Obstetrician/ gynecologist physician is on call in the delivery room. As the attending physician, this professional oversees patient care during delivery and may depend on the necessity avail themselves from the time the patient starts labor or arrives when the woman is ready to give birth.(High-Risk Labor and Delivery Case Study Comprehensive Nursing Essay Example)

• What would you report?

The labor and delivery nurse should report how many centimeters the dilated woman is and whether the cervix is thinning. The nurse may also on their determination of the baby’s position after having felt the presenting part. The nurse also reports whether the woman’s waters have broken when the client herself believes this has happened (Flores-Ghozales et al., 2019).(High-Risk Labor and Delivery Case Study Comprehensive Nursing Essay Example)

1. Within 15 minutes of your report, her physician arrives, confirms your assessment that Mallory is completely dilated, and wants her to start pushing.

You coach Mallory to begin pushing with her next contraction.

• What are your priorities in nursing care for Mallory?

The priority is to put the woman to bed followed by electronic fetal monitoring, then ensuring she has limited oral intake during labor and frequent vaginal examinations. In ineffective pushing, the patient needs to be placed in a supine position, usually stirrups, then be instructed to push using a closed glottis method during the contractions. However, care should be taken as the conventional closed glottis pushing can trigger suboptimal umbilical cord gases, fetal oxygen desaturation, and acidosis.(High-Risk Labor and Delivery Case Study Comprehensive Nursing Essay Example)

• Discuss the rationale for the priorities.

After admitting a patient in labor, the nurse should put the woman to bed. Bed rest or recumbent can lead to poor quality contractions, slow dilation and effacement, extended labor, and dystocia. Letting the mother have unrestricted labor during labor lets her find a more comfortable position, decrease maternal pain, and enhance maternal-fetal circulation. Whether intermittent or continuous, the initiation of EFM needs to be noninvasive with external monitoring or invasive with internal monitoring. Due to its risk of causing fetal hypoxia, it should only be reserved for high-risk cases, while limited oral intake offers some advantages like preventing ketosis and other adverse effects of keeping the patient with noting on the mouth. However, frequent vaginal exams should be limited as they put the woman at risk for chorioamnionitis and puerperal contractions.(High-Risk Labor and Delivery Case Study Comprehensive Nursing Essay Example)

• State nursing diagnosis expected outcomes and interventions related to this problem.

Anxiety emanating from the situational crisis and actual or perceived threats to self and the fetus. The anxiety may present as increased tension, apprehension, and sympathetic stimulation. The nurse should desire outcomes where the patient confirms anxiety has decreased and or is manageable, the patient appears relaxed, and her vital signs are within normal limits. The nursing interventions to initiate anxiety are to explain the procedures and treatment regimen as the information and knowledge can decrease fear of the unknown. The subsequent diagnosis is activity intolerance due to extended physical activity and stress and muscle hypersensitivity. The nursing team should offer comfort measures like back rubs and changes of position to decrease muscle tension and fatigue. Uterine muscle contraction and effects of medications may cause acute pain, possibly evidenced by the patient’s reports of pain or discomfort, narrowed focus, and muscle tension. Likely, nursing intervention for acute pain initiates bed rest for the mother and uses a lateral recumbent position. Lying on the side enhances uterine blood flow and could also decrease uterine irritability.(High-Risk Labor and Delivery Case Study Comprehensive Nursing Essay Example)

• What would you anticipate as Mallory’s teaching needs?

Mallory’s teaching needs require to be guided by her lack of information or misinterpretations. Mallory could also request specific information or verbalize misconceptions. The client’s knowledge concerning pre-term labor and possible outcomes and assessment of her readiness to learn would establish baseline assessment and identify the needs. Factors like anxiety and inadequate information, amongst others, maybe a barrier that has to be addressed first to improve retention of information.(High-Risk Labor and Delivery Case Study Comprehensive Nursing Essay Example)

• Over the next hour, Mallory’s contractions slow to every 7 minutes, and she is open glottis pushing and feels the urge to bear down with the peak of contractions every 3 to 4 minutes, and she is pushing has a strong urge to bear down with contractions. An SVE reveals fetal descent to +2 station.

You initiate oxytocin augmentation at one mu/min per physician order.

• Discuss the risk associated with oxytocin augmentation.

Cases abound of instances when women in labor have been given oxytocin inadequately or when not necessary. According to Mansy (2017), synthetic oxytocin augmentation has the risk of causing uterine hyperstimulation and other adverse effects like uterine rupture and fetal hypoxia.(High-Risk Labor and Delivery Case Study Comprehensive Nursing Essay Example)

• Outline nursing actions when caring for a patient with oxytocin.

The nursing administering oxytocin should monitor any signs indicative of asphyxia or fetal distress. These signs may manifest as meconium discharge, decreased or absent fetal movements, decreased fetal heart rate, and arrhythmia and report them to the attending physician immediately before administering oxytocin; conduct a 20 minute EFM and simultaneously assess fetal presentation and station. During oxytocin infusion, one must assess the fetal heart rate, contraction pattern, and intensity every fifteen minutes.(High-Risk Labor and Delivery Case Study Comprehensive Nursing Essay Example)

What teaching would you include related to oxytocin augmentation?

Most Modern healthcare facilities administer synthetic oxytocin to induce labor, yet inappropriate utilization of some high-risk drugs can lead to significant damage to the patient hence the need for education on oxytocin augmentation (Alan et al., 2020). Besides the five principles of drug administration, the provider should closely monitor the patient intake and outtake of fluids, the frequency of uterine contractions, the client’s blood pressure, and the heart rate of the unborn fetus. One must also have an infusion pump and frequently monitor fetal heart rate and strength of the contractions for safe oxytocin administration.(High-Risk Labor and Delivery Case Study Comprehensive Nursing Essay Example)

1. Within 30 minutes of starting the oxytocin, Mallory has UCs every 1 to 2 minutes lasting 45 to 55 seconds, moderate to palpation with relaxed uterine between contractions to 90 to 40 seconds with UCs, and FHR variability is moderate.

• What are your priorities in nursing care?

Assessment of fetus

Assessment of contractions

Monitoring blood pressure

Assessment of maternal electrolytes.

• Discuss the rationale for the priorities and nursing action?

The nursing care priorities are premised on the fact that oxytocin can cause asphyxia and intracranial hemorrhage (ICH) in the fetus or coma and painful contractions in the mother. As such, priorities are assessment of the fetus, assessment of contractions, close monitoring of blood pressure, and assessing maternal electrolytes. Assessment of FHR, contraction pattern and intensity of the contractions should occur every 15 minutes. Once a sufficient contraction pattern is determined, one has to assess FHR and contraction pattern and intensity every 30 minutes.(High-Risk Labor and Delivery Case Study Comprehensive Nursing Essay Example)

• What are your nursing actions based on your assessment?

The administration of oxytocin has an antidiuretic effect necessitating close monitoring of the patients in and out fluids to avoid water intoxication.(High-Risk Labor and Delivery Case Study Comprehensive Nursing Essay Example)

• State nursing diagnosis, expected outcomes?

If the patient has had oxytocin to induce labor or manage a post-partum hemorrhage, their fluid intake and outtake should be monitored. Effective monitoring would successfully induce labor and manage subsequent post-partum hemorrhage.(High-Risk Labor and Delivery Case Study Comprehensive Nursing Essay Example)

1. Over the next hour, Mallory’s contractions are every 3 to 4 minutes, and she is pushing with contractions and has a strong urge to bear down with contractions.

The FAR is 140s with moderate variability and variable decelerations to 100 bpm for 30 seconds with contractions and open-glottis pushing.

 Her SVE reveals fetal descent to +3 station.

• What are your immediate priorities in nursing care for Mallory?

With Mallory’s fetal station at +3, it indicates the baby is already within the birth canal. Fetal station, by definition, refers to how far the baby has descended in the pelvis and is a measure of the relationship of the baby’s head to the ischial spines (sit bones). These sit bones are located 3 to 4 cm insisted the vagina and constitute the reference point for the station score. Mallory’s pre-term labor necessitates the nurse reassess the fetal presentation and encourage her to lie on her left side. Conduct delivery very carefully. Keep one hand gently on the head as it advances with contractions. Support perineum with the other hand and use a pad to cover the anus with a pad held in position by the side of the hand during delivery. Leave the perineum visible, ask the mother to breathe steadily, and encourage rapid breathing with an open mouth.(High-Risk Labor and Delivery Case Study Comprehensive Nursing Essay Example)

• Discuss the rationale for the priorities.

Usually, the recommended delivery is by caesarian section to improve pre-term newborn outcomes, but since this client has a vaginal delivery, the nurse should call for help during delivery and conduct it carefully. The nurse should prepare resuscitation equipment for the newborn. The place of delivery should be clean and warm with a room temperature of about 25 degrees Celsius.(High-Risk Labor and Delivery Case Study Comprehensive Nursing Essay Example)

References

Alan, S., Akça, E., Şenoğlu, A., Gozuyesil, E., & Surucu, S. G. (2020). The Use of Oxytocin by Healthcare Professionals During Labor. Yonago Acta Medica, 63(3), 214-222.(High-Risk Labor and Delivery Case Study Comprehensive Nursing Essay Example)

Durham, F.D., & Chapman, L., (2019). Maternal-newborn nursing: the critical components of nursing care. 3rd ed. Philadelphia: F.A. Davis Company(High-Risk Labor and Delivery Case Study Comprehensive Nursing Essay Example)

Flores-Gonzales, P. D., Montesinos-Segura, R., Taype-Rondan, A., & Zafra-Tanaka, J. H. (2019). The potential excess of vaginal examinations during labor-management: frequency and associated factors in 13 Peruvian hospitals. BMC.(High-Risk Labor and Delivery Case Study Comprehensive Nursing Essay Example)

Mansy, A. (2017). Does Labor Augmentation with Oxytocin Increase the Risk of Postpartum Hemorrhage? A Randomized Controlled Trial. Clin. Mother-Child. Health, 14.(High-Risk Labor and Delivery Case Study Comprehensive Nursing Essay Example)

https://www.ncbi.nlm.nih.gov/