Bulaklak, John Reyniel T.

BSN-2

RLE ACTIVITY

Case Scenario:

Helena Lang is married 30-year-old gravida 2, para 1001 at 35 weeks. She arrives in the labor and delivery
room at the hospital complaining of membranes ruptured.

1. You are the charge nurse and admit H.L. Based on the information you have been given,
identify the two most likely diagnoses for H.L.
 Risk for preterm labor associated with premature rupture of membrane
 Anxiety related to actual threats to self and fetus

2. You need additional information from H.L. to determine what you will do next. What
important questions do you need to ask with H.L.?
 Ask the patient when was she feel that her membrane ruptured
 Ask the patient if she feels pain or any discomfort
 Ask if she has sexual intercourse with his partner
 Ask the patient if the fluid smells bad
 Ask if the entire fluid is stained with blood
 Ask if the colour of the fluid is dark or greenish

Case Study Progress

Drugs to slow down labor were given but despite this the labour progressed and the decision was taken to
proceed to a vaginal delivery as long as there was no fetal distress or pain in the abdominal scar. For some
reason a caesarean section was not considered at this stage, despite the original plan.

3. What are the signs and symptoms that patient H.L. labor is progressing?
 According to the data shown, patient is in already active labor. Contractions will be
stronger and longer, then it is accompanied by measuring the cm is her cervix with dilation
and the effacement. Increasing the pain in the backache would be likewise felt and leg
distress and patient will likewise encounter extreme fatigue.

Case Study Progress

An epidural drug was given, and after eight hours in labor the cervix was fully dilated and the baby’s head
was advancing well. After 4 hours, patient is exhausted and the fetus stayed in + 2 station. Decision taken to
deliver by forceps.

4. What are the indications that patient H.L is candidate for Forceps delivery?

 You're pushing, but labor isn't progressing. Labor is considered prolonged if you haven't
made progress after a certain period of time

 Your baby's heartbeat suggests a problem. If you are fully dilated, the baby is low in the birth
canal, and your health care provider is concerned about changes in your baby's heartbeat, an
 immediate delivery may be necessary. In such a case, he or she might recommend a forceps
delivery.

 You have a health concern. If you have certain medical conditions — such as heart disease or
high blood pressure — your health care provider might limit the amount of time you push.

5. Name at least two the possible maternal and fetal complications of forceps delivery?

Maternal Complications

 Uterine prolapse – it is when the uterus descend toward or into vagina. It happens if
muscles and ligaments become weak and are no longer able to support the uterus, which
causes overstretch.
 Hemorrhage – we all know that if there is a wound it can cause bleeding

Fetal Complications

 Facial Paralysis (Bell’s Palsy) - injury is induced by the pressure of the posterior blade of the
forceps which affects the facial nerve
 Skull Fracture - if forceps are applied unevenly to the baby's head or used with excessive
force, the strain on the baby's head could cause skull fractures.

Case Study Progress

H.L. had a 2nd degree perineal tear (laceration) even episiotomy was done. Vaginal repair was done.

6. What are your nursing responsibilities at this time?

Make a health teaching to the patient, which can help him to fast recovery.
 Use a peri bottle. Fill the bottle with lukewarm water and point the stream at the perineum
as urinating to eliminate stinging.
 Change pads often. This will help keep the area clean and dry and ward off bacteria
 Use cooling pads. Used to help treat hemorrhoids, they may help relieve burning and itching
around stitches.
 Try showering daily. Timing showers and bathing after bowel movements gives an
opportunity to wash away anything you missed that might infect your stitches.
 Drink plenty of water. Aim for six to eight glasses each day to help keep your bowel
movements regular and soft. If you’re worried about pooping with your stitches, that’s
completely understandable. Still, it’s necessary to avoid constipation, which could be a
whole lot more painful.
 Eat a varied diet. Be sure to opt for foods that are rich in fiber, such as fresh fruits and
vegetables, over cereal, whole grain breads, and pastas.
 Kegels Exercise. When you feel ready (as soon as 2 to 3 days after delivery), be sure to do
regular Kegel exercises to strengthen your pelvic floor muscles.

7. Make a Nursing Care Plan according to your answer in number #4. (one Nursing diagnosis for mother
and fetus
ASSESSMENT NURSING PLANNING
DIAGNOSIS GOAL / NURSING RATIONALE EVALUATION
EXPECTED INTERVENTIONS
OUTCOME
Cues/Data Risk for fetal Goal: 1. Assess FHR 1. Detects
injury Prevent fetal manually or abnormal
Objective: associated with injury electronically. Note responses, such
prolonged labor variability, periodic as, bradycardia,
Epidural drug was Expected changes, and and tachycardia,
given Outcome: baseline rate. which may be
caused by stress,
After eight hours in 1. Patient will 2. Assess for hypoxia, acidosis,
labor the cervix was participate in malpositioning or sepsis
fully dilated interventions to using Leopold’s
improve labor maneuvers and 2. Determining
pattern and/or findings on internal fetal lie, position,
reduce identified examination and presentation
After 4 hours,
risk factors. may identify
patient is exhausted factor(s)
3. Note frequency
and the fetus stayed of uterine contributing to
2. Patient will
in + 2 station. display FHR contractions. dysfunctional
within normal labor.
limits, with good 4. Identify maternal
variability, no late factors such as 3. Contractions
decelerations dehydration, occurring every 2
noted. acidosis, anxiety, min or less do not
or vena caval allow for
syndrome. adequate
oxygenation of
5. Administer intervillous
antibiotic to client, spaces.
as indicated.
4. Turning client
to lateral
recumbent
position can
increase
circulating blood
and oxygen to
uterus and
placenta and may
prevent or correct
fetal hypoxia

5. Prevents
ascending
infection and will
protect fetus as
well.