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Aklan Catholic College

Archbishop Gabriel M. Reyes St. 5600
Kalibo, Aklan, Philippines
Tel. Nos.: (036)268-4152; 268-9171
Fax No.: (036)268-4010
Website: http://www.acc.edu.ph
E-mail Add:aklancollege@yahoo.com
NURSING DEPARTMENT

OBSTETRICS and GYNECOLOGY Clinical

Marie Lucienne P. Tioco, RN, MAN
Clinical Instructor

Case Analysis

Instruction: Watch the Clinical Scenario Video Clip sent to you and complete the following needed information indicated below.
I. VITAL INFORMATION
Name of Patient SUSAN BROWN
Age 28 y/o
Date/Time Admitted 5:30 AM (no date mentioned)
Chief Complaint upon Admission Active labor
Medical History No known allergies, blood type: O positive, GBS negative, Rubella immune
II. CLINICAL ASSESSMENT (before code)
Obstetrical Score (GTPAL) G2, T0, P2, A0, L2
Type and Time of Delivery Precipitous vaginal delivery at 6:42 AM
Newborn Assessment 9lbs, 2oz (4173 g), APGAR 9/9
Intrapartum Assessment Objective:
Vital signs-
Temp: 98.8°F (37.1°C)
Pulse: 102bpm
BP: 116/72mmHg
RR: 18cpm
SpO2: 98% on room air
Active Labor
Spontaneous rupture of membrane at 6:10 AM
Had a precipitous vaginal delivery at 6:42 AM
Estimated blood loss (EBL) of 250 mL
18 gauge IV access, saline lock in left hand
Fundus is firm, midline, at the umbilicus
Voided 150mL about 30mins ago, refused pain medication
Breastfed after delivery with good latch for 30mins
Second degree laceration repaired with local, and had an icepack
Physical Assessment Vital signs:
 Vital Signs Mother:
 General Appearance Temp: 98.8°F (37.1°C)
 Systems Approach Pulse: 102bpm
RR: 18cpm
BP: 116/72mmHg
SpO2: 98% on room air
Newborn:
APGAR 9/9

General Appearance:
(Mother)
Second degree laceration repaired with local and an icepack noted
18-gauge IV access, saline lock in left hand
Fundus is firm, midline at the umbilicus noted
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Presence of 1 ear piercing on each ear noted

Hospital bracelet on right wrist noted

Systems Approach:
(Mother)
Integumentary
Pt has brown skin color
Pt has black wavy hair
Second degree laceration on the perineum (between the vagina and anus)
Presence of 18 gauge IV access, saline lock in left hand noted
White nail polish on fingernails noted
Neurological
GCS= 15
Pt was able to verify her name and date of birth
Pt was able to respond to questions correctly
Respiratory
RR: 18cpm
Pt did not exhibit signs of respiratory distress
Cardiovascular
Pulse: 102bpm
BP: 116/72mmHg
SpO2: 98% on room air
EBL of 250mL
Pt did not exhibit cardiovascular distress
Gastrointestinal and Genitourinary
Fundus is firm, midline at the umbilicus
Voided 150mL about 30mins ago as of endorsement
Musculoskeletal
Pt was able to move upper extremities without pain
Pt reported tiredness and soreness, but without pain
III. CLINICAL ASSESSMENT (during code)
Objective:
Vital signs (1st take during code):
Pulse: 116bpm
RR: 22cpm
BP: 95/55mmHg
Pulse oximetry: 94%

Vital signs (2nd take during code):

Pulse: 120
SpO2: 97%

Vital signs (3rd take during code):

Pulse: 120bpm
Pulse oximetry: 97% on rebreather mask
BP: 100/60mmHg

Boggy uterus upon palpation at 9:42AM

Excessive bleeding with clots upon palpation noted
Uterine atony noted due to retained placental fragments in the uterus

Subjective:
Pt exclaimed, “Ah! It feels like I’m peeing,” upon palpation of the uterus followed by excessive bleeding.
Pt expressed confusion on the episode of bleeding, “what’s happening?”
Pt expressed fear during the bleeding management, “this is so scary, what is happening?”; “I’m scared.”
Pt verbalized pain upon internal examination and manual removal of the retained placental fragments in the uterus.

IV. CLINICAL ASSESSMENT (after code)

Objective:
Vital signs:
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Pulse: 102bpm
RR: 22cpm
BP: 108/72mmHg
Pulse oximetry: 98%

Bleeding stopped upon removal of placenta fragments in the uterus.

EBL 550 mL
Fundus is firm and in midline

Subjective:
PRS of 2 from 1-10.
V. TREATMENT/ INTERVENTIONS GIVEN (enumerate below)
Intrapartum
Interventions:
Assessment and history- taking of the mother
Second degree laceration repaired with local and an icepack
18-gauge IV access, saline lock in left hand
Monitored vital signs
Fundal palpation
Offered with pain medication, but patient refused
Treatment:
500mL LR with 30 unit Pitocin after delivery

Postpartum (before, during, and after code)

Interventions:
(Before code)
Established rapport and asked for verbal consent in every step of the intervention
Mental status examination (MSE)
Took vital signs
Positioned the pt
Palpated the uterus
(During code)
Instructed the pt with deep-breathing upon call bleeding to alleviate stress
Proper endorsement
New members of the healthcare team during code established rapport
Asked for verbal consent every step of the intervention
Fundal massage
Monitored vital signs
Provided pt support
Recorded every step of the intervention
Inserted foley catheter to empty bladder
Administered 10L oxygen via rebreather mask
Manual removal of the placental fragments through insertion of hand in the vagina
(After code)
Fundal palpation
Midwife ordered EBL, Hemoglobin and Hematocrit (H&H) stat and new vitals
Monitored vital signs
Reassured the patient
Assessed the pt for pain
Debriefing

Treatment:
(During code)
Administered 30 units Pitocin in 500LR bolus
Administered Ketorolac 30mg IV push stat
Administered 800mcg cytotec rectal
VI. DRUG STUDY (utilize the Drug Study form of CON) NEXT DOCUMENT
VII. NURSING CARE PLAN (utilize the NCP form of CON) NEXT DOCUMENT