Age: 34 Yrs
LMP: October 28, 2015
EDC: August 10, 2016
Gestation: 40 weeks
Obstetric History: Elena is a 34-year-old female who presents to the maternity clinic with labor pains. The client is a G3 P3 T3 A0 L2. The previous children were delivered by normal vaginal birth. She had a pre-pregnant weight of 137 lbs and a current weight of 176 lbs.
First Stage of Labour
The patient reports that contractions started seven hours ago at home. The contractions are regular occurring after approximately five minutes with a duration of 45 to 60 seconds. The cervical dilation is at 6cm. After two hours, the contractions became stronger and prolonged lasting for about one and a half minutes and occur every two to three minutes. The cervix dilates to 10cm.
Interventions: Offer encouragement and emotional support. Encourage the patient to keep changing positions after about twenty minutes. Place the patient on continuous epidural of Fentanyl, 0.2% Noropin, and 0.25% Marcaine at 14mL/h. Performed an amniotomy (AROM) at full dilation (0845hrs) that resulted in a gush of clear fluid with no meconium stains.
Rationale: Human presence and support promote the mothers feeling of security. Frequent changes in position and ambulation(walking, standing, lying down, kneeling) help in relieving pain (Sics Editore, 2014). The epidural medication was administered to manage pain. The aim of the amniotomy was to accelerate labor.
Outcome: The drugs reduced the patient’s distress and pain. After the amniotomy, the baby’s head descends to the birth canal.
Second Stage of Labour
At this stage, the contraction rate increase to peak intensity and the baby descends firmly in the pelvis. The mother reports a strong urge to have a bowel motion and has involuntary bearing down movements.
Interventions: I continued to offer physical and emotional support. I placed the patient in a lithotomy position with her legs on stirrups (Sics Editore, 2014). I encouraged and motivated the woman to push, and gave her feedback after every push. A right mediolateral 20 episiotomy was done. This was followed by a normal spontaneous vaginal birth devoid of maneuvers or complications.
Rationale: Offering support helps the mother feel secure. Feedback after every push is helpful in keeping the woman motivated and focused on the birthing process. Episiotomy enlarges the vaginal opening facilitating delivery (Sics Editore, 2014).
Outcome: The mother stayed motivated and kept pushing until the baby was delivered. A healthy male neonate was delivered at 0925hrs on August 9, 2016. He had a birth weight of 3127g, a length of 51cm and APGAR scores of 81 and 95.
Delivery of the Placenta
After birth, the uterus continued to contract firmly. The uterine changes from a discoid to a globular ovoid shaped followed by a sudden flow of dark blood from the vagina. The placenta was delivered spontaneously and intact.
Newborn Examination and Care
Immediately after birth, the newborn was dried and assessed for any complications or defects. The Apgar scoring was conducted at one and five minutes after birth to determine the heart rate, respiratory effort, muscle tone, irritability, and skin color (Davidson, 2014). The baby scored 81 and 95. He was then wrapped in warm blankets and placed on the mother’s abdomen. The birth weight and the baby’s length were measured. Others measurements taken include head circumference, vital signs and abdominal circumference (Davidson, 2014). The child was given 1mg of vitamin K intramuscularly, and erythromycin eye ointment was applied to the eyes.
After twenty-four hours, the doctor did a comprehensive physical examination of the neonate. He examined each organ system carefully for signs of health, normal function, illnesses, and defects. This top to toe exam involves the assessment of the general appearance, skin, head/neck, face, mouth, lungs, heart sounds, abdomen, anus, genitals, and limbs. It also involves the evaluation of the newborn’s physical maturity (Davidson, 2014).
It is was the responsibility of the care provider to ensure that daily care is given to the baby appropriately. The baby’s neck, face, and arms were wiped daily. The cord was left dry, and nothing was applied to the stump after the initial triple dye application after birth. Care was taken to avoid soiling it or covering it with the diaper. The nurse took weight measurements every day (Davidson, 2014). The baby was kept warm at all times. He was also be breastfed on demand.
Post-partum Period
The patient experienced post-partum bleeding due a laceration in the birth canal that led to a constant trickle of blood from the vaginal opening. The damage was repaired surgically to stop the bleeding (Callahan & Caughey, 2013). After suture, the bleeding ceased.
The mother and child bonded very well. The baby breastfeeds heartily approximately six times in the last twenty-four hours. The mother stated that she is experiencing the letdown reflex each time the baby cries. The patient complains of dizziness while sitting, which increases upon standing. She reports a pain scale of 3/10 in the perineal and uteral regions. The dizziness is probably due to blood loss during and after birth (approximately 700ml). The patient was encouraged to take fluids in addition to I.V hydration.
Discharge Instructions
Before release, the baby was given BCG, OPV, and HB-1 vaccines (Callahan & Caughey, 2013). He was feeding well (at least eight times a day) and was not on any medications except vitamins. The patient and the newborn were discharged after three days with the following instructions:
Ensure you get enough rest during the first and second week after delivery. Do not drive or perform household chores
Continue breastfeeding the baby 8-12 times a day
Take well-balanced meals and plenty of fluids daily
Keep taking your vitamin and ferrous pills until the post-partum follow-up appointment.
You may experience tissue selling due to the episiotomy. Wash the perineal area well after urination or bowel motion with warm water. Take about two to three sitz baths a day. Use pads not tampons to catch the flow. Change the pad frequently.
Use mild analgesics (Tylenol) for uterine cramps and episiotomy discomfort.
Lochia flow will last for about 4-6 weeks. The discharge will change from bright red to dark brown and finally cream.
Contact a doctor immediately in case of heavy bleeding or a temperature of above 1010F
In case you have feelings of excessive sadness, over protectiveness about the baby or feeling incapable of caring for the newborn for over two weeks, contact your doctor.
References
Callahan, T. & Caughey, A. B. (2013). Blueprints obstetrics and gynecology. Philadelphia: Lippincott Williams & Wilkins
Davidson, M. R. (2014). Fast facts for the neonatal nurse: A nursing orientation and care guide in a nutshell. New York: Springer Publishing Company.
Sics Editore. (2014). Labour and delivery. Milan: Sics Editore
