Normal Pregnancy and Pain Management Case Study
Time: 1845
Heather Morris, RN, has just arrived to work her evening shift in Labor & Delivery. This is her 5th year as an RN in the unit. While waiting for report on her patient she reviews the chart, revealing the following:
Melanie Bauer, admitted 3 hours ago, is a 30-year-old gravida 3 para 1-0-1-1 married woman whose expected date of delivery is today. Her first prenatal visit was at 12 weeks and she had 10 visits total. Melanie’s lab work includes:
• Hemoglobin: 12g/dL • Blood type: A negative • VDRL: non-reactive • Urinalysis: normal • Rubella titer: 1:10
• Hepatitis B screen (HbsAg): negative • HIV screen: negative
• Pap smear: Negative Significant information:
• Melanie’s pre-pregnancy weight was 140 pounds, weight gain was 40#.
• Her baseline blood pressure was 110/64, BP’s remained 110-120/64-70 throughout her pregnancy.
• Her routine urine samples were normal and her chart reveals normal fetal growth throughout her pregnancy.
• She had 2 ultrasounds and did not want to know the sex of her baby. • A quad marker screen at 16 weeks was within normal limits.
• Melanie had a glucose screen at 24 weeks with a plasma glucose level of 110 mg/dL. • Her Group B strep screen at 36 weeks was positive.
• She remained healthy and active and medications included only prenatal vitamins daily.
• She did report problems with constipation and hemorrhoids during her pregnancy. In report, Heather learns that at her last exam 1 hour ago:
• Melanie’s cervix was dilated to 6 cm and 80% effaced, at a zero station. • The baby’s position is ROA.
• Spontaneous rupture of membranes occurred at home 6 hours ago, fluid was clear. • Melanie is having strong contractions every 2 minutes, lasting 60 seconds.
• Fetal heart tones are 140-150 with good variability. • Vital signs: HR – 90, RR – 20, Temp – 99.8, BP – 122/72. • She has an IV of LR in her right arm that is saline locked.
She and her husband are using their breathing techniques and managing the contractions well. They are really pleased that they did not have to be induced again like last time. Melanie hopes to have a natural childbirth without the use of drugs, which she also accomplished with her first delivery. She did relate that her contractions seem stronger this time and she may be rethinking that decision.
Melanie’s husband Mark is with her in labor, they have taken childbirth preparation classes. Mark was also present for the vaginal delivery of their son Simon who was born 2 years ago. The Certified Nurse Midwife will be attending the delivery though she is not currently on the unit. As the day shift RN leaves for home, Heather plans her evening and thinks: “I anticipate a routine delivery within the next few hours.”
If you were caring for Melanie, here are some questions to ponder:
What screenings were done antenatally and why—what other screenings might have been done?
Are constipation and hemorrhoids in pregnancy normal? Why?
What are other discomforts of pregnancy?
What is the significance of the client’s Rh negative status?
Is her weight gain appropriate for her pregnancy?
What are the implications of medications/drug use/ smoking use in pregnancy (including prenatal vitamins and folic acid)?
What the meaning of G3P1011?
What is the significance and expected management of her group B strep positive status?
What stage of labor is she in and how does the baby’s position affect the progression of labor?
How does a patient stay hydrated in labor?
What are the implications of a full bowel or bladder in labor?
What breathing techniques would be most advantageous for the patient to use in labor in each stage?
How can the nurse support the family unit?
How does the nurse prepare for a routine delivery?
How is the laboring progress described and what is is the expected course of labor?
If Melanie does change her mind regarding medication in labor, what might you suggest and what are the implications for the fetus?
What are standards of care related to fetal monitoring and documentation?
How would you document her labor progress?
What would concern you on the fetal monitor tracing?
Time: 1930
As Heather prepares to meet her patient and do an assessment, Mark runs out of the labor room and is clearly upset and anxious. He yells: “You need to hurry, she wants something for pain and she says she feels like pushing. The baby’s heart rate is slowing down and I can hear it!” Heather knows that the nurse midwife is at home at least 20 minutes from the hospital. Heather recalls that at the last exam one hour ago, Melanie was only 6 centimeters dilated and only 80% effaced. She had planned to ask Melanie how long her labor was with her son, but is now concerned that this labor may be progressing more quickly. She is concerned that Mark is anxious and worried and clearly wants her attention.
What should the nurse do first?
What would you include in your SBAR communication with the provider?
What is the information acquired during a vaginal exam?
How do you assess fetal status and what would you expect as normal?
What is the significance of feeling pushy?
What does Heather need to know about pain management at this point in labor?
What is the best response to Mark to help him manage his anxieties about the baby?
Time: 2100
The midwife, Cara, has been on the unit for one hour. She ordered Nubain 10 mg IV which was given when she arrived. Melanie is now completely dilated and she has been pushing for ten minutes. The baby is crowning. The FHT’s are dropping down to 90 bpm from a 140bpm baseline with each contraction. Mark continues to support her and seems to be less anxious
now that Cara is here. He has questions regarding whether an episiotomy could help labor progress faster, and is this amount of bleeding normal? He continues to express concern about the fetal heart rate dropping.
What effect is Nubain going to have on the fetus and how will this affect nursing care of the infant?
What are indications for an episiotomy and nursing implications for patient teaching?
What is the estimated blood loss for a normal vaginal delivery?
How will blood loss impact hemoglobin, hematocrit and vital signs?
How and why do FHT’s change during a normal delivery?
Time: 2110
Melanie delivers a baby boy who is immediately placed on her abdomen. His Apgars are 8 at one minute and 9 at five minutes. Cara waits 10 minutes for the placenta to be delivered intact. Sharon persuades Mark to cut the cord and he has tears in his eyes as he and Melanie marvel over their new son. The baby is awake and Melanie wants to know if it is too soon to breastfeed. They begin discussing the need to have their baby circumcised and ask you for your thoughts on the matter.
How should the nurse respond to Melanie’s question about breastfeeding?
What can be expected of the infant’s behavior over the next few hours?
What assessments should the nurse do for a newborn and what teaching is critical?
What is involved in Melanie’s post-partum checks and what are normal findings?
What teaching will Melanie need before she is discharged?
How should the nurse respond to Melanie and Mark’s questions about the necessity for circumcision?
What information should the nurse give Melanie regarding follow-up care for herself and the baby?
