labor and delivery assessment2nd sem

8/3/2019 Labor and Delivery Assessment2nd Sem

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West Visayas State UniversityCOLLEGE OF NURSING

La Paz, Iloilo City

LABOR AND DELIVERY ASSESSMENT

I. VITAL INFORMATION

Name: MCA Date of Interview: December 3,2011

Age: 21 years old Informant: MCA

Address: Brgy. Tu-og, Leon, Iloilo Relationship to Patient: patientherself

Civil Status: SingleDate and Time Admitted: December 3, 2011; 9:00 AMChief Complaint:Ward: OB WardBed No.: No. 10Allergies: none as claimed (as of present)Religious Affiliation: Roman CatholicPhysicians Initials: Dr. LImpression/Diagnosis:

II. CLINICAL ASSESSMENT

II.A. Obstetrical data

1. Age of Menarche: 15 years old

2. G1P1(T0P0A0L0)

3. Description of Previous Pregnancy: N/APregnancies Type of Delivery Complications of Labor and

DeliveryN/A N/A N/A

4. LMP: March 07, 2011

5. EDC: December 14, 20116. Prenatal Check-Ups:

Date Remarks and Treatments Done

03-12-11 Negative uterine contraction; prescription of Folic acid 5mg, vit B Complexand Duphaston for hypogastric pain

04-09-11 Negative uterine contraction; prescription of Folic acid 5mg, vit B Complex,Caltrate, one glass of Anmum and Duphaston for hypogastric pain

05-19-11 Negative uterine contraction; maintenance of prescribed drugs and dilutedHydramnous sugar with Calamnsi; 1st dose of tetanus toxoid

06-23-11 Negative uterine contraction; prescription of Folic acid 5mg, vit B Complex

and Caltrate and one glass of Anmum; 2

nd

dose of tetanus toxoid07-24-11 Negative uterine contraction; maintenance of prescribed drugs, subjectedfor urinalysis, Blood typing and HcgAg

09-02-11 10 kicks for one day was noted at house: maintenance of prescribed drugs09-07-11 Maintenance of prescribed drugs

7. Description of Present Pregnancy:LJA suspected that she was pregnant because of amenorrhea for two months. LJA

experienced nausea and vomiting during first Trimester. LJA claimed that she was

Vision: WVSU as one of the top 10 universities in Southeast Asia

Mission: To produce globally competitive life long learners


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admitted to Don Benito for four days during her first Trimester because ofstomachache. The stomachache was suspected appendicitis. She was subjected toCBC, blood typing and urinalysis. The admission in Don Benito hospital was the wayfor her parents to discover her pregnancy that was keep secrete for two months.Negative Appendicitis was the findings. She was advised to take more rest and wasprescribe Duphaston for hypogastric pain. LJA claimed that she never experienced

edema or swelling in lower extremities during her 3rd Trimester.LJA also observedstretch marks during her 3rd Trimester.

8. Medications Taken During Pregnancy:

Name of Drug Dosage, Frequency, and RouteFolic acid 5mg, one tab once a day, oral

Vitamin B complex One capsule once a day, oral

Duphaston 10mg, one tab three times a day for

hypogastric pain, oralCaltrate One tablet once a day, oral

9. Discomforts on Present Pregnancy:

LJA claimed that she experienced nausea, vomiting and hypogastric pain during her1st Trimester. She experienced vertigo when she was stressed due to overwork. Shealso claimed that she experienced shortness of breath during late 2nd trimester and3rd trimester.

10.Progress of labor

11.Description of Each Stage of Labor (Textbook Discussion)A.

1. First Stage of Labor

Time Duration

Interval

Intensity

Time Duration

Interval

Intensity

1.40 2.35 1.52 2.151.25 0.20 2.17 2.190.45 3.10 1.57 2.501.05 2.05 1.10 1.552.15 2.43 1.45 1.252.05 0.25 2.15 3.402.55 2.45 2.10 3.201.50 0.20 1.15 2.051.45 0.45 2.30 3.100.30 1.55 2.05 0.452.35 1.55 1.55 0.351.35 1.05 2.15 2.052.45 1.05 2.15 1.551.20 1.50 1.07 2.001.15 2.30 1.23 1.151.05 3.30 0.57 3.472.15 2.20 2.10 1.151.30 2.49 1.37 2.20

1.43 3.15 1.07 2.372.30 2.20 1.47 4.021.00 2.00 2.37 1.57


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The first stage of labor is divided into three phases: the latent, the

active and the transition phase.

Latent Phase

This phase begins with the onset of regularly perceived uterine

contractions and ends when rapid cervical dilatation begins. Contractions

during this phase are mild and short, lasting 20 to 40 seconds. Cervical

Effacement occurs, and the cervix dilatates from 0 3 cm. This phase lasts

approximately 6 hours in nullipara and 4.5 hours in multipara.

At this stage, the woman can continue to walk and make final

preparations for her childbirth process.

Active Phase

During this phase, cervical dilatation occurs more rapidly, increasing

from 4 to 7 cm. Contractions grow stronger lasting 40 to 60 seconds, and

occur approximately every 3 to 5 minutes. This phase lasts approximately

3 hours in nullipara and 2 hours in multipara. Show (increased vaginal

secretions) and perhaps spontaneous rupture of the membranes may

occur during this time

This phase can be a difficult time for a woman because contractions

grow so strong, last longer, and begin to cause true discomfort.

Transistion Phase

During this phase, contractions reach their peak of intensity,

occurring every 2 to 3 minutes with a duration of60 to 90 seconds and

causing maximum dilatation of 8 to 10 cm. If the membranes have not

ruptured or been ruptured by amniotomy, they will rupture as a rule at full

dilatation (10cm). If it has not previously occurred, show occurs as the last of

the mucus plug from the cervix is released. By the end of this phase, both full

dilatation (10cm) and complete cervical effacement have occurred.

During this phase, a woman may experience intense discomfort, so

strong that it is accompanied by nausea and vomiting. Because of the

intensity and duration of the contractions, a woman may also experience a

feeling of loss of control, anxiety, panic, or irritability.

The peak of the transition phase can be identified by a slight slowing in

the rate of cervical dilatation when 9 cm is reached. As the woman reaches

the end of this stage at 10 cm of dilatation, a new sensation occurs. (e.g., an

irresistible urge to push)


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Types of Placenta:

1. Schultze placenta

- appearing shiny and glistening from the fetal membranes

- if placenta separates first at its center and lastly itsedges, it tends to fold on itself like an umbrella and

presents at the vaginal opening from the fetal

membranes

2. Duncan placenta

- if placenta separates first at its edges, it slides along the

uterine surface and presents at the vagina with maternal

surface evident

- looks raw, red, and irregular with the ridges or cotyledonsthat separate blood collection spaces showing.

The normal blood loss is 300 500mL.

Placental Expulsion

After separation, the placenta is delivered either by natural bearing

down of the mother or by pressure on the contracted uterine fundus by thephysician or nurse-midwife (Credes maneuver). Pressure must never be applied

to a postpartal uterus in a noncontracted state, because doing so may cause

the uterus to evert and hemorrhage. This is a grave complication of birth

because the maternal blood sinuses are open and gross hemorrhage may occur.

If the placenta does not deliver spontaneously, it can be removed

manually. With delivery of the placenta, the third stage of labor is over.

4. Fourth Stage of Labor

The fourth stage of labor or the recovery stage is the first few hours

after birth.

Oxytocin

Once the placenta is delivered, osytocin is usually ordered to be

administered intramuscularly or itravenously to the mother. Such medication

increases uterine contractions and minimizes uterine bleeding.

Oxytocin (Pitocin) may be added to an existing intravenous line (20 to

40 U/L in intravenous fluid) or given as 10U intramuscularly. Do notadminister it until the physician or nurse-midwife indicates its appropriate.

Perineal Repair


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After delivery of the placenta, any necessary perineal stitching is

performed. This process can be a long, tedious one from the mothers

perspective.

Theoretically, if suturing of an episiotomy is done immediately after the birth

of the placenta, a woman who gave birth without anesthesia will still have somuch natural pressure anesthesia of the perineum and that she will not

require any anesthetic.

Immediate Postpartum Assessment and Nursing Care

Obtain vital signs every 15 minutes for the first hour and then

according to the agencys policy. Pulse and respirations may be fairly rapid

immediately after birth and blood pressure slightly elevated due to the

excitement of the moment and recent ocytocin administration. Palpate the

womans fundus for size consistency, and position. And, observe the amount

and characteristics of lochia. Perform perineal care and apply perineal pad.

B. Schematic Diagram

Latent Phase mild

uterine contraction

0 3

cm cervical dilatation

Active Phase

moderate uterine contractions

4 7 cm

cervical dilatation

Predisposing Factors- Female

- Reproductive age (15-45 years

old)

- Coitus

Precipitating Factors- Uterine contractions

- AOG ( weeks)

- Lightening


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Nausea and vomiting - - - - - - - - - - - Transitional Phase severe

uterine contractions

8 10 cm cervical

dilatation

Full cervical

effacement

Irritability

Bleeding

Diaphoresis

Anxiety

Engagement

Descent

Flexion

Internal Rotation

Extension

Rupture of BOWPain


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External Rotation

Expulsion

Placental separation

Schultzes presentation

Placental delivery

Fourth Stage of

Labor

C. Management

Normal Spontaneous VaginalDelivery (NSVD)

Calkins SignSudden Gush of Vaginal bloodLengthening of the umbilical cordPresence of the placenta in thevagina

WeaknessFatiguePain


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a. Nursing

Nurse coaches mother about the labor process, how to do deep

breathing exercises, and to push during contractions.

Ambulation is promoted if there are no contraindications

Proper monitoring of Vital Signs especially if there is a drug

therapy. (e.g., oxytocin drip)

Relieve muscular aches by giving a massage.

Performs Leopolds maneuver.

Promote breast hygiene.

Promote perineal self-care.

Patient and Family Education especially on wound care, and

baby care.

b. Medical

Administration of Oxytocin to promote uterine contraction to

prevent hemorrhage should be prescribed by a physician.

Oxygen therapy was started as ordered.

Intravenous line may be started upon the indication of the

physician.

c. Surgical

Episiotomy is a surgical incision of the perineum that is made

both to prevent tearing of the perineum and to release pressure

on the fetal head with birth. It is made with a blunt-tipped

scissors in the midline but directed laterally away from therectum (mediolateral episiotomy). Mediolateral episiotomies

have the advantage over midline cuts in that if tearing occurs

beyond the incisions, it will be away from the rectum, creating

less danger of complication from rectal mucosal tears.

Episiorraphy is a surgical procedure inorder to repair

episiotomy.

References: 2007; Pilliteri, Adelle; 5th edition Maternal and Child Health Nursing:

Care of the Childbearing and Childrearing Family

12.Type of Anesthetic Used: Lidocaine HCl13.Type of Episiotomy and Description: mediolateral episiotomy

14. Type of Delivery: NSVD

15.Type of Bow Ruptured: Induced


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16. Description on Placental Delivery: Spontaneous

B. Gynecologic HistoryM.C.A. claimed that she has not experienced any problems during her

pregnancy.

C. Family PlanningM.C.A knows about contraceptive pills but she is still not sure if she would

have a family planning in which she leaves the decision to her husband.

D. Past Health Problems

a. Childhood IllnessesM.C.A. said that her mother used to tell her that she had a pulmonary problem

that she was admitted to the hospital (unrecalled) when she was 5 years old.

b. ImmunizationsM.C.A. claimed that she is fully immunized since childhood but had a recent

Tetanus toxoid injection for her pregnancy.

c. AllergiesM.C.A. claimed that she no known allergies to food or drugs.

d. Accidents and InjuriesM.C.A. stated that she has a cut caused by a binangon while she was

chopping wood for their fire in cooking.

e. Hospitalization for Serious IllnessM.C.A. was admitted due to a pulmonary problem in a hospital (name unrecalled)last 1995.

f. Medications

Oxytocin 1 amp IM StatHyoscine-N-Butylbromide 1amp IM StatAmoxicillin 500mg 1cap TID for 7 daysIron folic plus 1tab 325mg OD

E.Family History of Illness

Maternal(-) hypertension(-) diabetes(-) asthma

Paternal(-) hypertension(-) diabetes(-) asthma

F. Patients Expectations

a. What she expects to occur during this hospitalization?MCA expects that she will have a fast recovery after the delivery of the baby.

b. What she expects regarding nursing care?MCA expects that the nurse will follow her up during her hospitalization. She alsoexpects that nurses would give some health teachings about caring for the baby.


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II.A.5. Patterns of Functioning

A. Breathinga. respiratory problems: shortness of breath with marked congestiondescribed as

though the whole thorax is displaced by multiple

fetusesb. usual remedies: lying down with loosened clothesc. manner of breathing: deep, rapid diaphragmatic breathing

B. Circulationa. usual blood pressure: 90/60-110/80 mmHgb. history of chest pains, palpitations, coldness of extremities: none as

claimed

C. Sleepa. usual bedtime: 8:30-9:00 pmb. number of pillows: two (one for the head, one between the legs)

c. bedtime rituals: praying, half-bathingd. problems on sleep: none as claimede. usual remedy: N/A

D. Drinking Patterns

Kinds of Fluid in 24hours

Amount

WaterJuiceCoffeeMilkSoft drinks

10001250 mL400 mL200 mL200 mL200 mL

Total = 2000- 2250 mL

E. Eating Patterns

F. Elimination patterns1. Bowel Movement

Frequency: twice per week- twice per dayProblems or Difficulties: loose bowel movementUsual remedy: 500mg loperamide per day, one (tundal) banana

2. UrinationFrequency: twice or thrice per dayProblems or Difficulties: noneUsual remedy: N/A

Breakfas

t

Lunch

Dinner

Snacks

Usual Food Taken Time

Two cups of rice, one sunny side up egg, onesmall bowl of noodles

7:00am -8:00 am

Two cups of rice, one fried fish, one smallbowl of tinola

11:30am12:00nn

Two cups of rice, one fried fish, one smallbowl of tinola

7:00pm-8:30pm

Five pieces of pan de leche 2:30pm-3:00pm


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G. Exercise1st trimester- walking around the house for 30 minutes2nd trimester- walking around the house for 15 minutes

H. Personal Hygienea. bathing:

i. type: morning bathing, half-bathii. frequency: twice per day

iii. time of the day:8:30am-9:00 am; 8:00-8:30 pmb. oral care:

i. frequency: thrice a day after each mealii. care of dentures: not applicable

c. shaving: does not perform shaving as claimedi. frequency: not applicable

d. use of cosmetics: use of blush-on powder and lipstick

I. RecreationM.C.A loves listening music to radio, and watching television for 2 hours.

j. Health Supervisionclaims that she seeks for pre-natal check-up every month during the first andsecond trimesters. On her third trimester of pregnancy, she seeks for pre-natalchek-up once per weekPrenatal check up at Dr. CSC, MD. Clinic on the ff days:1st Trimester - 03-12-112nd Trimester - 04-09-11

05-19-1106-23-11

3rd Trimester - 07-24-1109-02-1109-07-11

III. A. CLINICAL INSPECTION1. Vital Signs Date and Time Taken:

T= PR=BP= RR=

2. Height: 149 cm 3. Weight:

4. Physical Assessment

GENERAL APPEARANCE:

A. CENTRAL NERVOUS SYSTEM/ SENSORY ASSESSMENT/ NEUROLOGICALASSESSMENT


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B. CARDIOVASCULAR SYSTEM

no pulsations nor lifts over aortic, pulmonic, tricuspid, and apical areas; aortic pulsations are palpable at theepigastric region; S1 heard loudest at apical area, S2 heard loudest at base of the heart; Grade II carotid,

antecubital, radial, and tibial pulses; prompt capillary return at 2s; no bruises on the body;

C. RESPIRATORY SYSTEMsymmetric thorax; symmetrical chest expansion; lowest point of

resonance between 8th and 10th posterior ribs; auscultated vesicular andbronchovesicular without adventitious breath sounds

D. GASTROINTESTINAL SYSTEMLips- pink, softest and smooth, oral mucosa, moist and intact

Teeth- 20 healthy teeth, 2 decayed teeth and 2 missing teeth

Tongue- pink, moist, and papillae present, moves freely and symmetricallyFrenulum- in midline and visible veinsSoft and hard Palate- intact and no lesions

Tonsils- pink and smooth, grade 2, positive gag reflexAbdomen- loose, presence of striae gravidarum and linea nigra, inverted and

at midlineumbilicus, audible borborygmi on right lower quadrant with 7 cycles/

minute

Cranial Nerves Testing ResultI. Olfactory Smells and discriminates

various aromasAble to smell anddiscriminate variousscents and aromas.

II. Optic Reads name plate at adistance of 2 feet.

Able to read name plateat a distance of 2 feet.

III. Occulomotor Pupils equally round andreactive to light andaccommodation; moveseyes with 6 cardinal fieldsof gaze.

Pupils are equally round,reactive to light andaccommodation.Difficulty and pain feltupon moving eyes in the 6cardinal fields of gaze.Pain rating of 7.

IV. Trochlear Moves eyeball up anddown freely.

Able to move eyeballs upand down freely.

V. Trigeminal Clench jaw and wispcotton.

Able to clench jaw anddetect the presence ofcotton touching the face.

VI. Abducens Moves eyes laterally. Able to freely move eyeslaterally.

VII.Facial Lifts eyebrows, puffscheeks, smile, bear teeth.

Able to lift eyebrows, puffcheeks, smile and bearteeth without difficulty.

VIII. Auditory Voice/Whisper test. Able to hear and repeatwhispered word at adistance of 2 feet.

IX. Glossopharyngeal Swallow. Able to swallow withoutpain and difficulty.

X. Vagus Gag reflex. Positive gag reflex.XI. Spinal Accessory Shrug shoulders, moves

head side to side withresistance.

Able to shrug shouldersand move head side toside even with andwithout resistance.

XII.Hypoglossal Stick out and movetongue.

Able to stick out and movetongue freely.


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E. GENITO-URINARY SYSTEM

Urinary bladder- palpable over symphysis

F. REPRODUCTIVE SYSTEM

Mons pubis- normal pubic hair distribution is in the shape of an invertedtriangle, no signs of

infestationLabia majora, labia minora- labia are equal, dark pink, and moist,Perineum- right mediolateral episiotomy is free from pus and inflammation,

scant lochia rubradischarge

G. LYMPHATIC SYSTEM

no enlargement or tenderness of cervical, mamillary, and axillary lymphnodes; no enlargement of spleen

H. ENDOCRINE SYSTEM

palpable, non-tender thyroid gland; profuse perspiration

I. HEMATOPOIETIC SYSTEM

J. MUSCULOSKELETAL SYSTEM

Lordotic posture, steady gait with opposing arm swing, arm muscle strengthgraded 5/5, can perform ROM with difficulties in left arm and lowerextremities, able to perform ADL such as walking, eating and drinking

K. INTEGUMENTARY SYSTEM

Dried circular scabs and marks noted on both feet. Overall skin is dry,brown and intact. Negative for edema on extremities. No redness andwounds identified. Minimal striaegravidarum observable.negativeforchloasma, melasma and erythema, as well as varicosities.Hair is dull and dry. Scalp is intact without dandruff and negative for liceinfestation.Nails are trimmed but smudged with dirt.

III. OTHER SOURCES OF LABORATORY DATA


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A. Hematology

Name of Examination: Complete Blood Count (CBC)Definition: Blood test ordered to determine general health status and to

screen for a variety of disorders, such as anemia and infection.Preparation: Blood sample collected by injecting a needle and placing it in a

vein in the arm.Purpose: Determines the value and concentration of varying blood

components with each value is compared to a standardinternational range constant.

Date: 09-12-11

Blood Components Results Normal Values Significance of Results

Hemoglubin Mass Concentration 118 gms./li 120-150gms./li Below normalvalue

Erythrocyte Volume Fraction 0.35 li/li 0.37-0.45 li/li Below normalvaue

Erythrocyte NumberConcentration

3.96x1012/Li

4.0 x1012-5.0x1012/Li

Below normalvalue

Leukocyte NumberConcentration

15.8x109/Li 5.0 x1012-10.0x1012/Li

Normal

Other findings:Blood Type: O Rh+

B. UltrasonographyName of Examination: UltrasonographyDefinition: Use of non-invasive and non- harmful soundwaves in order to

determine physical characteristics of the fetus as well as itsinternal structures and surrounding membranes and todetermine its overall health condition.

Preparation: Using a lubricant, the sensor is placed above the mothers

abdomen and is gently moved across.Purpose: Determines fetal physical character and overall health conditionDate: 07-08-11

File #: 2011- 07-260 Age: 23 years oldLMP: 12-09-10 Clinical Impression: PU, 30

1/7 weeks AOG for fetalbiometry

EDC: 9-16-11

AOG: 30 1/7 weeksPlacental Examination:

Neutrophil Number Fraction 0.76 0.55-0.70 Slightly abovenormal

Segmenters 0.76 Below normalvaue

Lymphocyte 0.24 0.2-0.4 Normal value

Thrombocyte Number Fraction Adequate Adequate Normal

Data: RemarksBPD: 7.50cm 30weeks

OFD: 9.78cm 30weeksCI: 76%HC: 27.37cm 29weeks & 6 days

FL: 5.49cm 30weeks & 5 daysAC: 25.73cm 29weeks & 6 daysSEFW: 1531gGender: MaleFHR: 127bpm


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*Anterior lowest edge is 8.9cm from os*Grade 1 and 3.6cm thick*Amniotic Fluid Index: 17.10cm

Fetal Anatomic Survey Remarks

Lat. Vent Not dilatedTCD Not enlargedC. Magna Not dilatedNuchal fold Not thickened4C Heart Looks normalDiaphragm IntactIntestine Looks normalBladder Looks normalStomach Looks normalKidney Looks normalColon Looks normal

Spine Intact

Ratios:

Others:(+) Cardiac and somatic activities on real-time. The cervix is 3.8cm

long. Intact fetal lips. No obvious structural anomalies noted in the present

scan. **A segment of the cord is seen in close proximity to the neckindenting the nuchal skin on sagittal view.

Impression:

Pregnancy uterine, 30 weeks 1 day by average sonar age (EDD= 9-15-2011+/- 2weeks).Cephalic, live, singleton. Highly lying anterior placenta.Male fetus. Normohydramnious. SEFW= 1531gSuggested daily fetal movement counting.

Problem List:

Data Normal Value SignificanceHC/AC:1.06FL/AC: 31% 20%-40% NormalFL/BPD: 73% 71%-87% Normal

labor and delivery assessment2nd sem

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