February 26, 2008 CSU San Bernardino Maternal and Neonatal Nursing Labor and Delivery: Worksheet #7 GENERAL

INFO Client: 3405-A Age: 21 G2 T0 P0 A1 L0 LMP: June 1, 2007 EDC: March 11, 2008 Obstetrician: Roloff Support Person: Family Prepared childbirth class: No Date/Time to hospital: 2/25 @ 0800 Admitting Dx: 38 1/7 weeks labor induction ASSESSMENT Height: 57 Weight: 264 Hgb/Hct: 11.3/33.1 (L) Rh/Type: A+ Coombs: Negative VDRL: Nonreactive GC: Negative Chlamydia: Negative BetaStep: POSITIVE: Risk for maternal bladder and womb infection. Risk for neonatal meningitis, sepsis, and pneumonia. HIGH RISK FACTORS 1. Bipolar Disorder:Risk for severe anxiety, postpartum depression. 2. GBS positive:Risk for maternal bladder and womb infection. Risk for neonatal meningitis, sepsis, and pneumonia. Last Ultrasound Info: December 26, 2007 1. Single live intrauterine gestation consistent with 19 weeks 3 days +/- 10 days gestation and approximate EDC by ULT March 11, 2008. 2. Vertex presentation. 3. Placenta posterior not previa. 4. EFW: 2365g +/- 355g, EFW% 53. 5. Amniotic fluid index: 15cm. LABOR ASSESSMENT Start of Labor: 2/25 @ approximately 1200 Contractions: Positive Labor induction via Pitocin.Risk for uterine hyperstimulation or rupture, fetal hypoxia, fetal distress, and postpartum hemorrhage. Interval: Approximately 2-3 minutes apart as of 1300 Duration: Approximately 40-60 seconds Intensity: Moderate-strong Membranes: SROM at approximately 0915 Fluid: Clear with no foul smelling odor. SVE >>Dilation: 4-5cm Effacement: 80% Station: -2 FHR: 135-145 FM: IUPC placed at 1000 Variability: Moderate

Reassuring: YES Comments: Pt complains of pain level of 8-10 during contractions. Anesthesiology was called, but they were unsuccessful in placement of an epidural. The pt was then medicated with narcotics (Stadol), after which her pain level decreased to 2-3 during contractions. Pt also previously complains of constipation and has been administered Colace. Pt chooses not to breastfeed because she wants to take her medications for bipolar/depression disorder after birth. These medications are incompatible with breastfeeding. MEDICATIONS PCN 5ml IV x1 bolus PCN 2.5ml IV q4 until delivery LR IV 125ml/hour Motrin 600 mg PO q6prn/pain Iron 300mg PO TID Colace 100mg PO BID Multivitamins 1 tab PO QD Stadol 1mg IVP Q3-4hrs until delivery: Riskfor maternal and neonatal respiratorydepression. Phenergan 1mg IVP Q3-4hrs until delivery. Exam/Procedures: 10+ prenatal visits at ARMC womens health clinic Pap smear: WNL Fundus: 38.5 Last US on December 26, 2007 see results above. Braden score: 23: low risk Comfort measures: Pain medication, lying on side. TREATMENTS IV: Right wrist, saline lock Diet: Regular Void: 5-6 x/day, yellow, clear. Last void was at 0930, QS. BM: 1-2 x/day, brown and formed. Last BM was yesterday at 2100. Emesis: Pt reports very few episodes of emesis since first trimester. Activity: Ambulatory as tolerated. Comments: Attempted epidural placement at approximately 1100 unsuccessful. Pt is of Caucasian ethnicity. No cultural or spiritual needs at this time. DELIVERY N/A: Pt did not deliver. PROGRESSION OF LABOR Time 0800 Dilation 3cm Effacement 70% Station -1 Frequency 5-7 minutes FHR 140-150 Reassuring X Non-reassuring BP 12272 P 91 1000 4-5cm 70%% -2 5 minutes 140-150 X 132/80 90 1200 5cm 80% -2 3 minutes 140-150 X 135/77 95

R 18 18 20 T 97.1 98.0 97.8 CLIENT/FAMILY EDUCATION Pt oriented to room and environment, call bell, bathroom, etc. Pt understood and responded appropriately. Pt educated about ongoing assessments, labor process, EFM, and then IFM. Pt understood and responded appropriately. Pt educated about relaxation techniques; visualization, breathing, music, etc. Pt understood and responded appropriately. Pt educated on need to change positions in order to avoid vena cava syndrome. Pt understood and responded appropriately. Pt has been educated on to benefits of skin-to-skin and en face positioning after birth. Pt understood and responded appropriately. PROMOTION OF MOTHER/BABY ATTACHMENT Pt was encouraged to perform En Face positioning whereby the mother holds the infant close with face-to-face and eye-to-eye positioning, cuddles and soothes, calls baby by name, identifies characteristics of family members in infant. Pt understood and responded appropriately. Pt was encouraged to have skin-to-skin contact between 30 minutes and 2 hours post birth. Pt understood and responded appropriately. NDX#1: Physical Diagnosis Pain r/t uterine contractions, cervical dilation, and fetal descent AEB pt states pain level of 810during contractions. Goal:By end of shift, the nurse will minimize the pain level of the pt to a level of 4 or less. Expected Outcome:By end of shift, the pt will establish and maintain an optimal comfort level and active reduction of pain by performing pain-relieving techniques as encouraged by the nurse, and administration of analgesia or anesthesia agent. NDX#2: Physical Diagnosis Risk for maternal or neonatal injury r/t prenatal risk factors: GBS positive. Goal: By end of shift, the nurse will ensure that all necessary precautions are taken to avoid maternal and/or neonatal injury. Expected Outcome: By end of shift, mother and fetus will have no adverse effects related to prenatal risk factors during labor. NDX#3: Psycosocial Diagnosis Risk for postpartum depression r/t hx of maternal diagnosis of bipolar and depression disorder Goal: By end of shift, the nurse will use educational measures and comforting techniques to relieve anxieties and identify any potential risk factors that may lead to postpartum depression. Expected Outcome: By end of shift, the mother and support persons (family) will verbalize understanding of pt teachings related to postpartum depression and associated risks. Pt will acknowledge decreased anxiety as a result of proper education and comforting techniques.