ANGELES UNIVERSITY FOUNDATION

Angeles City
College of Nursing
RELATED LEARNING EXPERIENCE (RLE) 0109
CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEM
(ACUTE AND CHRONIC)
Second Semester, Academic Year 2020 – 2021

MODULE 6:
STORIFIED CASE SCENARIO

Submitted by:

JINGCO, Jashtine E.

BSN II – D

Submitted to:
Karen Cyril Cayanan, RN, LPT, MN

March 04, 2021

Maria 40 weeks AOG went to the admitting section in the labor room with chief
complain of true labor contractions. Upon initial interview she is a G5P4 patient who
was diagnosed of Gestational DM on her 34th week AOG.

1. If you are the nurse who will care for this patient, what signs and symptoms will you
take note that the patient is already experiencing true signs of labor. Explain your
answer. (10points)

SIGNS OF TRUE LABOR

 Uterine Contractions. During early labor, uterine contraction begins irregularly

but become regular and predictable. It is felt first in the lower back and sweeps
around to the abdomen in a wave pattern. It continues no matter what the
woman’s level of activity. It increases in duration, frequency and intensity with the
passage of time.
 Cervical Dilation and Effacement. Effacement and dilation are result of
effective uterine contractions. During labor, the cervix will gradually thin and
stretch. Uterine contractions will increase the diameter of the cervix by pulling it
upward over the presenting part of the fetus. This also happens since the fluid-
filled membranes press against the cervix.
 Show. As the cervix softens and ripens, operculum, the mucus plug that filled the
cervical canal during pregnancy is expelled. The exposed cervical capillaries
seep blood as a result of pressure exerted by the fetus. This blood, mixed with
mucus takes on a pink tinge and is referred to as “show” or “bloody show.”
 Rupture of the amniotic membrane. Labor may begin with rupture of
membranes, experienced either as a sudden gush or as scanty, slow seeping of
clear fluid from the vagina.

After the initial assessment, Maria was admitted in the labor room. The doctor ordered
IVF of PNSS 1 liter regulated at 30gtts/min. Random Blood Sugar was also done with a
result of 110mg/dl.
2. Labor room nurses must be knowledgeable on the events that happens during the
labor process. In line with this, describe the first stage of the labor process. (9
points)
 Latent phase – This phase begins with onset of regular contractions and ends
with a complete effacement of 100% and cervical dilatation of 3cm. Mild
contractions occur regularly 10 to 20 minutes apart and a short duration of 20 to
40 seconds. The pregnant woman usually experiences low backaches,
abdominal cramps and she is generally excited, alter, talkative and in control.
This phase lasts approximately 6 hours in nullipara and 4.5 hours in multipara.
 Active phase – This phase begins with complete effacement and cervical
dilatation of 4 to 7 cm. Uterine contractions occur at 3 to 5 minutes apart and
lasts up to 40 to 60 seconds. Contractions become stronger, and last longer. This
phase begins to cause discomfort and she may realize that labor is truly
progressing. This phase lasts approximately 3 hours in nullipara and 2 hours in
multipara.
 Transition phase – During this phase, the contractions reach their peak of
intensity, occurring every 2 to 3 minutes with a duration of 60 to 90 seconds and
causing maximum dilatation of 8 to 10 cm. She may experience a feeling of loss
of control, anxiety, panic, and irritability. Her focus is entirely on the task of
birthing her baby. As she reaches 10 cm dilatation, an irresistible urge to push
begins to occur.

3. Nursing care for pregnant women in labor proves to be a challenging task because it
requires nurses to be fast in their assessment without sacrificing the quality and
accuracy of rendered nursing care. What nursing interventions will you do in each
phase of the 1st stage of labor for you do deliver quality care to this patient? (9
points)
Latent Phase
 Monitor vital signs to obtain a baseline for later comparison.
 Assess the contraction patterns as well as the fetal response and FHT.
 Assess the patient’s psychological readiness.
  Provide information about labor, birth, breastfeeding and newborn care.
 Provide non-pharmacologic techniques to alleviate pain like controlled breathing,
distraction, and aromatherapy.
 Perform vaginal examination to evaluate dilation and effacement progress.
 Anticipate patient’s needs (e.g., keeping her bed clean and dry, sponging face
with cool cloth, assistance in going to the bathroom, etc.).
 Encourage patient to void every 2-3 hours to avoid bladder distention.
 Maintain the women’s parenteral fluid intake at the prescribed rate.
Active Phase
 Inform the patient and her partner on the progress of labor to lessen anxiety.
 Continue monitoring vital signs.
 Continue monitoring contraction and FHR
 Report any deviations from normal to the healthcare professional so that
interventions can be initiated early.
 Start monitoring labor progress with the use of partograph.
 Maintain the women’s parenteral fluid intake at the prescribed rate.
 Assist the woman and her partner to focus on breathing technique.
 Encourage the patient to have drink sips of water and eat dry crackers to regain
energy and prevent hypoglycemia.
 Determine when patient last voided because a full bladder can hinder fast labor
progress.
 Inform the woman that the discomfort will be intermittent and encourage her to
rest between contractions to preserve her strength.
 Reposition the woman as needed to obtain optimal heart rate pattern.
Transition Phase
 Monitor maternal vital signs frequently and report any abnormal findings.
 Maintain the women’s parenteral fluid intake at the prescribed rate.
 Ensure that the patient performs pant-blow breathing before and after each
contraction.
 Monitor FHR for accelerations, decelerations, and variability.
  When perineal bulging is noticeable, notify the team and prepare necessary
equipment for delivery.

The doctor ordered to attach the patient on External Fetal monitor.

4. What is/are the purpose/s of the External Fetal Monitor in the case of the patient? (3
points)
The purpose of external fetal monitoring in this case is to assess the fetal well-
being of the patient during labor. This will help monitor the fetal heart rate pattern,
especially during contractions.

5. What are the nursing interventions you need to implement when placing the patient
in external fetal monitor? (5 points)

 Establish rapport with the patient.

 Ask for the patient’s consent in performing the procedure
 Explain the purpose of external fetal monitoring
 Provide privacy by exposing the abdomen only.
 Inform the patient that a clear gel with be placed on her abdomen.
 Place the 2 two transducers: one in upper segment of abdomen to record
contractions, and the other in the side where fetal heartbeat was detected.
 Instruct the patient to limit movement as it may affect the results.

You checked the external fetal monitor strip and you have noticed this pattern.

6. What is the interpretation of the fetal monitor strip? (2 points)

The fetal monitor strip indicates that there are early decelerations

7. What is the cause of this pattern? (2 points)

 Early decelerations are caused by fetal head compression during contraction,
which results in vaginal stimulation and slowing of the heart rate.

8. What interventions must you do for this pattern? (2 points)

Early decelerations do not require any treatment since they are not associated
with fetal distress. However, it is important to continue monitoring FHR tracings
throughout the labor in order to recognize any patterns that may cause concern with
regards to the changes in the acid-base status of the fetus.

After 2 hours, the patient complains of intolerable pain. She is irritable and narrowed
focus. She has difficulty following instructions. She complains of strong contractions
coming 3-5 minutes apart that last for 60 minutes. Internal examination revealed that
her cervix is 65% effaced and is 6cm dilated, station at -1. She requested for pain relief
measures. The doctor ordered epidural anesthesia.

9. What are the contraindications that the nurse should be aware of when
administering epidural anesthesia? Explain each. (10 points)
 Patient refusal. Counseling concerning the purpose, course of action, and side
effects of epidural anesthesia is essential to gain the consent of the client prior
the procedure. However, the fear of being slightly numb at their lower extremities,
awake and aware during the procedure is a contributory factor for client to refuse
the administration of epidural anesthesia which contraindicates the management.
Therefore, upon refusal of treatment, the nurse must provide a refusal form
signed by the client and document it to her chart.
 Maternal coagulopathy. Similarly, since the clotting ability of the mother is
impaired, administering epidural anesthesia may lead to further blood loss,
having coagulation problems may increase the tendency for the client to bleed
which may result to hemorrhagic complications.
 Local skin or soft tissue infection at the proposed insertion site.
Microorganisms can enter the epidural space through hematogenous spread
from other areas of the body, or through an infected skin, wound, the patient’s
 catheter, and more. Hence, putting the patient at risk for meningitis or spinal
epidural abscess.
 Septicemia. Septic clients manifest unstable hemodynamic states because of
hypotension or cardiomyopathy due to vasodilation. Hence, it deteriorates the
client’s tissue perfusion and oxygenation that threatens the function of major
body organs. Therefore, it is contraindicated because the side effect of
hypotension could further impair the tissue perfusion of the body and depress the
cardiovascular system that could result to septic shock.
 Increased intracranial pressure. Clients with elevated ICP cannot received
epidural anesthesia because this medication may further increase ICP which
may rise to complications such as brain injury or spinal cord injury.

10. Enumerate the nursing interventions that you need to institute for patient’s receiving
epidural anesthesia. (5 points)

 Closely monitor the patient including vital signs, pain intensity rating,
sedation score, and degree of motor and sensory block.
 Assess the patient for signs and symptoms of complications associated with
the use of epidural analgesia including hypotension, nausea and vomiting,
urinary retention, and motor block.
 For patient experiencing hypotension, increase IV fluids and identify the
etiology of the hypotension.
 Assess respiratory rate and level of consciousness during the entire time
the infusion is used to prevent, monitor and manage respiratory depression.

After 1 hours the contractions become infrequent, contractions of 2 in 10 minutes, with

strength of 15 mmHg, duration of 15 seconds. Upon internal examination the cervix is
70% effaced, still at 6cm dilation and station is still at -1.

11. Based for the signs and symptoms presented by the patient, the patient is probably
experiencing what problem? (2 points)
 Based on the signs and symptoms presented by the patient, she is experiencing
hypotonic uterine contractions. This occurs when the number of contractions is low or
infrequent and when the contractions are 2-3 or less in a span of 10 minutes with a
contraction strength that does not rise above 25 mmHg. Also, the duration of
contractions of the patient lasts for only 15 seconds which is bel ow the no r mal
range of 20-30 seconds.

12. What could possibly contribute to the problem? Explain. (6 points)

One of the factors that may have contributed to hypotonic uterine contraction
includes an overdistended uterus and overused uterus due to grand multiparity, multiple
gestation, and possible fetal macrosomia because the mother was diagnosed of GDM in
the current pregnancy. The use of epidural anesthesia may also contribute to this
problem, since epidural makes labor less painful and laborious, which may hinder the
descent of the fetus and the anesthesia that has been given, may reduce the
effectiveness of the woman's voluntary pushing efforts. Lastly, inadequate contact of the
presenting part into the lower segment as evidence by -1 station can contribute to this
problem.

13. What are the assessment and diagnostic tools we can use to further evaluate the
present problem? Explain each assessment evaluation on how it can detect the
problem. (8 points)
 Ultrasound. An ultrasound is an imaging test that uses sound waves to create
an image of how a baby is developing in the womb. It is used to measure the
baby’s head and body size. Using the standardized growth chart, measurements
are being evaluated to determine if malposition, malpresentation, if baby is
macrosomic and the risk of cephalopelvic disproportion.
 Clinical pelvimetry. This is used to assess the size of the birth canal and it can
identify cephalo-pelvic disproportion, which is when the capacity of the pelvis is
inadequate to allow the fetus to negotiate the birth canal. This is done either with
the use of hands or a pelvimeter.
  Partograph. Partograph aids in comparison with the expected limit of normal
labor progress. A deviation to the right of the normal labor curve on the
partograph denotes slow progression.

14. What medical management will you anticipate the doctor will order after ruling out
CPD problem? Explain the importance of the management. (4 points)
After ruling out the CPD problem, the medical management that the nurse should
anticipate, provided that there are no contractions, includes the administration of
oxytocin and performing a procedure known as amniotomy. Oxytocin is used to
strengthen the uterine contractions and increase its effectiveness. On the other hand,
amniotomy is the artificial rupture of membranes which can stimulate contractions
through the release of prostaglandins and reflex stimulation of the uterus when the
presenting part becomes closely applied to the lower uterine segment. Amniotomy
should be attempted when vaginal delivery is probable, wherein the cervical dilation
>4cm means there is an adequate fetal descent, and the presenting part is well applied
to the lower uterine segment.

15. As the nurse who will take care of this patient, what the plan of care will you include
to manage her current problem? Explain the rationale behind your interventions. (8
points)

 Monitor the patient’s vital signs and fetal status and note for any changes or
variability from the normal range. Rationale: To check if there are any signs of
bleeding or leaking of the amniotic fluid.
 Monitor the patient’s uterine contractions. Rationale: To check for any changes
with the hypotonic contractions.
 Explain to the patient the labor progress as well as the procedure that she might
undergo such as amniotomy in a simple and concise manner. Rationale: Helps
the patient to have a better understanding of her situation and feel more in
control.
  Observe the patient for any signs and symptoms of infection. Rationale: Since
the cervix is dilated for a longer period, this increases the risk of the mother to
acquire infection.
 Provide continuous reassurance to the mother. Rationale: Maternal stress
increases endogenous adrenaline, which can inhibit uterine contractions. This
will also help in calming the mother.
 Perform a nipple stimulation. Rationale: To stimulate the release of natural
oxytocin
 Provide non-pharmacotherapeutic pain relief methods such as breathing
techniques. Rationale: To reduce pain and provide the patient with a sense of
control.
 Instruct the mother to empty her bladder. Rationale: Distended bladder obstructs
the descent of the baby.
 Maintain adequate hydration. Rationale: To increase the perfusion in the uterus.

 Administer oxytocin as per doctor’s order. Rationale: Combining oxytocin with

amniotomy strengthens the uterine contractions during the active phase.

One hour after implementation of the medical management, her cervix dilated to 10 cm,
100% effaced, and at station is +3. She begins to push, but the fetal head comes out
and goes back in.

16. What is the possible problem is the patient experiencing? Explain. (4 points)

Based on the signs and symptoms presented in the scenario, the patient is
experiencing shoulder dystocia and this happen because after vaginal delivery of the
head, the baby’s anterior shoulder gets caught above the mother’s pubic bone. The
patient is at risk for this condition because she has diabetes, which predisposes her
baby to be macrocosmic. In the scenario, the patient is in her second stage of labor in
which the occurrence of shoulder dystocia usually happens around that time as well.
Fetal macrosomia can cause a baby to become wedged in the birth canal because their
size is larger than the average baby which causes the mother to experience difficulty
during labor. The signs of shoulder dystocia include retraction of the baby’s head back
into the vagina which is known as the turtle sign.

17. What position will you recommend the mother to assume to aid in the delivery of the
baby? Describe the position and explain the importance of the position (6 points)

McRoberts maneuver is used to assist in childbirth and is done by flexing and

abducting the maternal hips. This position helps to widen the pelvic outlet by flattening
the sacral promontory and increasing the lumbosacral angle, which may help the
anterior shoulder to be born.

18. What possible complications can arise because of this problem to the baby and the
mother? (5 points)
Maternal Complications

 Cervical or vaginal tears

 Postpartum hemorrhage

Fetal Complications

 Cord compression between fetal and bony pelvis

 Fracture of the clavicle
 Fracture of the humerus
 Brachial plexus injury
 Hypotonic brain injury

REFERENCE

Book:
Silbert-Flagg, J. and Pilliteri, A. (2018). Maternal child health nursing: Care of the
childbearing and childrearing family. Volume 1 (Philippine edition); 8th edition
Philadelphia: Lippincott.

Internet Sources:

Capital Women’s Care. (n.d.). Labor and Delivery. Retrieved March 04, 2021 from
https://www.cwcare.net/services/obstetrics/labor-and-delivery

Contractions and signs of labor. (2021). Retrieved March 04, 2021 from
https://www.marchofdimes.org/pregnancy/contractions-and-signs-of-labor.aspx

GP Notebook. (2021). Hypotonic uterine action. Retrieved March 04, 2021 from
https://www.gpnotebook.com/simplepage.cfm?
ID=295305225#:~:text=Contractions%20may%20be%20strengthened
%20by,the%20use%20of%20intravenous%20syntocinon.

Khan, L. (2019). Shoulder dystocia. Retrieved March 04, 2021 from

https://teachmeobgyn.com/labour/emergencies/shoulder-dystocia/

Mona, S. (n.d.). Epidural analgesia: What nurses need to know. Retrieved March 04
2021 from https://www.nursingcenter.com/ce_articleprint?an=00152193-
201208000-00015

WebMD. (2020). Signs of labor. Retrieved March 04, 2021 from

https://www.webmd.com/baby/labor-signs#1

Tabangcora, I. R. (2017). Stages of labor. Retrieved March 04, 2021 from

https://nurseslabs.com/stages-of-labor/

Themes, U. (2021). Complications of Labor and Birth. Retrieved March 04, 2021
f r o m https://nursekey.com/complications-of-labor-and-birth-2/

Reiter & Walsh. (n.d.). Cephalopelvic disproportion injuries. Retrieved March 04, 2021
from https://www.abclawcenters.com/practice-areas/prenatal-birth-
injuries/traumatic-birth-injuries/cephalopelvic-disproportion/#treatment