Case Study

INTRAPARTAL
CARE
NCMA217 RLE - BSN 2-A-3
GROUP 4
Members:

Ajielaida Sandang
Bea Manalili
Laurence Anthony Gallego
Francheska Ann Reyes
Francheska El Luat
Irish Torres
Jorella Pialane
Kamea Villanueva
Sofia Ramos
Trishia Marquez
Case Scenario:
Isa Martinez, RN, has just arrived to work on her morning shift in Labor &
Delivery. This is her 5th year as an RN in the unit. While waiting for a
report on her patient, Isa reviews the chart, revealing the following:
Andi Soriano, 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.
Andi’s lab work includes:
• Hemoglobin: 12g/dL
• Blood type: A positive
• VDRL: non-reactive
• Urinalysis: Normal
• Rubella titer: 1:10
• Hepatitis B screen (HbsAg): negative
• HIV screen: negative
• Pap smear: Negative Significant information:
Andi’s pre-pregnancy weight was 140 pounds, weight gain was 40lbs. Her
baseline blood pressure was 110/70, 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 gender of her baby. Andi 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 the report, Isa learns
that at her last exam 1 hour ago: Andi’s cervix was dilated to 6 cm and 80%
effaced, at a zero station. The baby’s position is ROA. A spontaneous rupture
of membranes occurred at home 6 hours ago, fluid was clear. Andi is having
strong contractions every 2 minutes, lasting 60 seconds. Fetal heart tones
are 130-150 with good variability.
Vital signs: HR – 85, RR – 18, Temp – 37.2’C, BP – 110/70.
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. Andi 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.
Andi’s husband Kiko is with her in labor, they have taken childbirth preparation
classes. Kiko was also present for the vaginal delivery of their son Travis 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 night shift RN leaves for
home, Isa plans her day and thinks: “I anticipate a routine delivery within the
next few hours.”
Instruction:
If you were caring for Andi, answer the following questions:
 QUESTIONS:

1. What screenings were done antenatally and why—what other screenings

might have been done?
Although Andi almost completed all the necessary screenings for her pregnancy
that includes:
CBC test HIV screening
Blood Test Pap smear test
Ultrasound Screening
VDRL test
Glucose screening
HCG test Group B strep screen test
Rubella test Urinalysis test
HbsAg test Contraction stress test
 QUESTIONS:

Andi must do:

Non-stress Test
The test checks to see if the baby responds normally to stimulation and is getting
enough oxygen. A baby that doesn't respond isn't necessarily in danger, though
more testing might be needed.
Genetic screening
Genetic screening can help diagnose the potential for certain genetic disorders
before birth.
Screening for Infectious Diseases
Screening for infectious diseases like STDs that can affect the baby during birth can
help both mother and baby.
Amniocentesis Test
To check if the baby has a genetic or chromosomal condition, such as Down's
syndrome, Edwards' syndrome or Patau's syndrome.
 QUESTIONS:

2. Are constipation and hemorrhoids in pregnancy normal? Why?

Hemorrhoids and constipation are normal and common throughout pregnancy. Slow
peristalsis carried on by pressure from the expanding uterus causes constipation.
Constipation can cause dry or difficult-to-pass feces. Generally speaking,
constipation is defined as having less than three bowel motions per week.
Hemorrhoids caused by the larger uterus place additional stress on the big vein
(inferior vena cava), which drains the veins of the large intestine. Hemorrhoids may
be quite uncomfortable and could irritate and cause slight bleeding. Your body's
hormonal fluctuations slow down digestion, which helps you have regular bowel
motions.
The extra weight from the waste stuck in your bowel can squeeze the veins in your
anus so that it’s harder for them to move blood. Straining to poop adds even more
pressure.

 QUESTIONS:

3. What stage of labor is she in and how does the baby’s position affect the progression of
labor?
Since Andi’s cervix was dilated to 6 cm and 80% effaced, at a zero station this is considered as
Stage 1, the active (transitional) labor. In this stage, contractions aren’t yet strong or regular.
The cervix is essentially “warming up,” softening, and shortening as it prepares for the main
event.
The baby’s position is ROA( Right Occiput Anterior), in this baby's fetal presentation the baby
enters the mother’s pelvic region, from the right, in the anterior position (facing the mother’s
spine.)
These are the certain factors that can affect labor in the ROA fetal position:
Baby’s chin being towards or away from its chin
Balance and tone of the soft tissues involved in childbirth(uterus, ligaments, fascia)
Pelvic alignment (this affects the above-mentioned balance and tone)
Pelvic shape and size
Placental location

 QUESTIONS:

4. How does a patient stay hydrated in labor?

Patient will be hydrated during labor by:
1. Eat High-Energy Food- Load your system with stomach-friendly complex
carbohydrates (grains and pasta) that will deliver a moderate, constant flow of
energy during the hours of hard work ahead. Later in labor, snack on or drink simple
carbs that leave the stomach quickly and offer short bursts of energy: fruits, juices,
and honey.
2. Choose Stomach-Friendly Foods- Some moms suffer nausea during birth and find
drinking and eating unappealing. Nonetheless, they must eat. Bring foods and
beverages that have proven to be favorites all through the early, nauseous months
of pregnancy. Avoid greasy and fried meals, gassy foods, and carbonated
beverages- you have enough work going on within you without making your
intestines labor as well.
 QUESTIONS:

4. Drink plenty of water or liquids- This depletes your energy, upsets your body’s
physiology, and slows labor and this helps to keep the muscles working well and to
keep your energy up. Pre-load your tank with at least 8 ounces of water per hour in
early labor, and sip between contractions. Be sure to bring water bottles with your
favorite fluid to the hospital; place them within easy reach at your bedside.

3. Consider Intravenous “Feedings”- This can perk up a stalled labor or an

exhausted mom, An additional benefit: more fluids mean more trips to the
bathroom, which, because of the walking and squatting, are themselves labor
stimulators.
 QUESTIONS:

5. What are the implications of a full bowel or bladder in labor?

When in labor, a full bladder can become bloated and prevent the baby from
descending into the pelvis. Additionally, it could make it difficult for a baby to
get into a good position for birth. This is one of the reasons it is advised for
women in active labor and beyond to use the restroom once every hour. If the
patient’s bladder is full, Her labor could prolong and her contractions could
become weaker. Additionally, a full bladder might result in pain, difficulties
ejecting the placenta, and postpartum hemorrhage.
 QUESTIONS:

6. What breathing techniques would be most advantageous for the patient to

use in labor in each stage?
BREATHING PATTERN FOR THE FIRST STAGE OF LABOR: Early labor
Slow breathing - When a contraction is strong enough to prevent the
pregnant woman from moving or speaking through it without halting, start
breathing slowly. As long as the patient finds it helpful.
Light Accelerated Breathing - This is used when the contractions get more
intense; it involves rapid and shallow breathing through the mouth at a rate of
one breath per second.
Variable (Transition) Breathing - This breathing method can be used if the
pregnant woman is feeling exhausted. Take one to 10 breaths through your
mouth every second and breathe out the deeper breath every fourth or fifth
time.
 QUESTIONS:

SECOND STAGE OF LABOR: Active Labor

Expulsion breathing
This used once the cervix if fully dilated and the second labor began. The
mother should exert downward pressure on the diaphragm and the abdominal
cavity to assist in pushing the baby out.
 QUESTIONS:

7. How can the nurse support the family unit?

The nurse can help the family by suggesting ways to help and facilitate
Andi's delivery. Since she can no longer handle the pain, and it is different
from what she experienced in her past pregnancies, it would be better to
suggest ways to reduce the pain she feels. The nurse can show her support
by agreeing with the decisions of Andi and her husband yet at the same
time, suggest a much better solution on what they have decided.
 QUESTIONS:

8. What non-pharmacological comfort measures can the nurse provide?

During labor and delivery, comfort techniques that offer natural pain relief can be
extremely helpful. Here are some of the non-pharmacological comfort measures
that can reduce or modify labor pain without causing harmful effects to both
mother and baby.
Make sure patient Andie is well hydrated, but only offer clear liquids such as
water, juice, and ice.
Taking in consideration the movement or positioning of the mother such as
sitting, standing, kneeling, and walking. Moving is usually more comfortable
than staying still and laying down. It can also relieve some of the pressure.
Suggest patterned breathing or breathing techniques such as organized
breath, slow breathing, light accelerated breathing, variable breathing and
expulsive breathing.
 QUESTIONS:

Emptying the bladder can also allow your baby to descend in the pelvis and
means that contractions can be more efficient.
Massages provide a sense of comfort, care, and reassurance to the mother
and can convey pain-reducing messages. It can come in the form of light
touches, firm stroking, kneading, deep circular movements/pressure and
effleurage (a type of self-massage that focuses on your abdomen)
Applying heat or cold compresses on separate parts of the body at the same
time can provide particularly effective pain relief. Such as warm bottles, warm
and moist bath towels, ice bags, and washcloths soaked in cold water.
Focus and Distraction help reduces fear, anxiety, and pain, and can also be
helpful with any discomfort. I should help the patient envision and focus on
pleasant scenes and memories reassured with verbal coaching. While
distraction is more on the passive side by focusing on the surroundings to
draw attention away from the pain.
THANK YOU!