Labor And Delivery Nursing A Case Study

Labor and Delivery Nursing: A Case Study

Introduction

Tracy Hapman is a 28 years old woman. She is a black American and she lives with her husband in one of the middle income suburbs. This is her first pregnancy, and she has never had any abortions or still births before. Tracy is a seventh day Adventist. As such, there were some problems encountered as far as her prenatal case is concerned. According to her religious faith, one is not supposed to attend hospitals. It is common among this congregation for pregnant women to deliver at home. However, her husband, Kirk Hapman, who himself is not a seventh day Adventist, was able to convince her to have a hospital delivery.

Tracy started to attend antenatal clinic at the seventh month of her pregnancy. According to her obstetrician, there were no problems with the pregnancy. She started to experience her first signs of labor on week thirty six. She started experiencing minor contractions which lasted for three days. The obstetrician noted that her cervix had dilated to two centimeters. Tracy reported that the contractions were sporadic and not too painful. At the first sign of these contractions, she was anxious and had Hapman drive her to the hospital.

After the obstetrician assured her that everything was alright, Tracy’s moods brightened, a stance that she maintained throughout the early stages of labor. Her husband insisted that she be admitted. This been her first birth, the doctor concurred with Hapman, so that Tracy can be closely monitored.

Tracy has no relevant health history. She was categorical that under no circumstances should blood transfusion be carried out on her. This made the doctors anxious, for she will be at risk if she lost a lot of blood during delivery. No amount of persuasion from her husband or the hospital staff could make her change her mind.

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Labor and Delivery Nursing: A Case Study

Stages of Labor

There are four stages through which labor progresses. This when a vaginal birth is taking place. Tracy, having experienced a vaginal birth, progressed through all of the stages. The following section is going to describe all of the four stages, with reference to Tracy’s childbirth.

First Stage

This is also referred to as latent phase or prodromal labor (Parsons, 2008). To some women, this phase may take several days. There are sporadic contractions that are not very painful. It begins at about the 26th week of gestation. The contractions that are experienced at this phase are an extension of Braxton Hicks contractions (Parsons, 2008). These are the contractions that normally occur throughout the pregnancy, starting from around the sixth week. They are caused by the tightening of the uterine muscles. They last for about two minutes. Braxton Contractions prime the body for birth.

There is also cervical effacement during this phase. This is where the cervical muscles thins and stretches. It is what is also referred to as cervical dilation. When this stage comes to an end, this effacement is either complete or nearly complete (Murdaugh, 2008). A vaginal examination is the sure way of determining how far effacement has progressed. This is indicated by either a long or short cervix. The latter indicates that effacement has progressed far while the former shows that not much has occurred.

By the end of this stage, the cervix is about three centimeters dilated (Glazernh, 2009). The end of this stage is marked by the onset of the second one. This second one is referred to as the first active stage of labor.

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Labor and Delivery Nursing: A Case Study

Tracy’s Latent Phase

The patient’s prodromal labor lasted for three days. There was vaginal examination to feel for the extent of cervical effacement. At the first day of admission, a vaginal examination revealed that the cervix was still long. This was an indication that not a lot has taken into her lower segment. During this time, Tracy was in a nervous, jovial mood. She took walks with her husband around the hospital block, but her husband refused to let her go home.

The contractions were approximately one hour apart during the first day of admission. However, when she was admitted to the labor ward on the third day, the contractions were ten minutes apart. An abdominal examination showed that the fetus was normally positioned. Her effacement was three centimeters at the end of the latent phase.

Active Stage of Labor

The latent and active stage of labor usually forms the first stage of labor. The active stage follows the latent immediately. At this stage, effacement of the cervix is faster. At the end of this stage, the cervix is fully dilated at 10 centimeters. The membranes are likely to rupture as the mother progresses through this stage. They may be accompanied by bloody shows in some cases (Hosster, 2009).

The muscles of the uterus form into opposing spirals. These start at the top of the uterine upper segment to where it meets the lower segment. The cervix becomes merged with the lower segment of the uterus. This occurs during effacement (Glazernh, 2009). The contractions take place when the upper segment shortens and the lower one is drawn up. This is the reason why at the end of this stage, there is a shortening of the cervix as these segments merge. According

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Labor and Delivery Nursing: A Case Study

to the Friedman curve, cervix dilation takes place at a speed of about 1.2 centimeters per hour (Hosster, 2009).

The duration of this stage varies from one woman to the other. For the primiparae, it might last for about eight hours (Murdaugh, 2008). However, for women with multiple births, it can be as short as four hours.

The patient is allowed to move around at this stage. She shower and sit around between the contractions. She is also allowed to sip clear fluids. If there is a need for medication, it is delivered intravenously. This is the stage where medication is administered, especially pain relievers, if the mother wishes so (Glazernh, 2009). Extra fluids are also administered intravenously.

A lot of monitoring, both for the mother and the fetus, is carried out periodically. The cervix is also examined to determine the progression of the labor. The position of the baby is also monitored. At the end of this stage, the baby’s head is facing downward, and its face is on the direction of the mother’s rectum (Glazernh, 2009).

Tracy’s Active Stage

The patient’s active stage lasted for four hours. She broke her waters one hour into the active stage. Her contractions were about three minutes apart. Each contraction lasted about 40-60 seconds. She asked for intrathecal as a pain medication. However, we could not get access to the intravenous rig. As such, she had to do without any pain medication in her delivery.

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Labor and Delivery Nursing: A Case Study

Tracy’s cervix was determined to be 7 centimeters. It has effaced 92 percent. The vertex was at 0 station. Fetal heart tone (FHT) was monitored using Electronic Fetal Monitoring. The use was intermittent. The heart rate of the fetus was constant. It was recorded at 120. There were no decelerations. The baseline was steady. This could be attributed to the fact that no pain medication had been administered.

Second Stage of Labor

This starts when the cervix is fully dilated. It is the hardest stage of labor, and the mother feels the need to push. Tracy was discouraged from screaming. However, she was advised to mourn in order to relieve some of the pain, given the fact that she had not been given pain medication. At this stage, the fetus, which had been positioned just above the cervix, gets its head into the birth canal (Parsons, 2008). This stage takes between 30 minutes and three hours. This is for the first time mothers. But for those women who had given birth before, it may take five to thirty minutes. The baby positions itself such that it is facing either the left or the right side of the mother’s pelvis.

The heart rate of the fetus is monitored periodically. This is to make sure that there is no distress from the labor. When the head of the baby starts to emerge from the birth canal, this is referred to as crowning (Murdaugh, 2008). In some cases, there is the need to perform an episiotomy, where the vagina is surgically incised to widen the canal for the easier passage of the baby. This is necessitated in cases where the perineum is not big enough for the passage of the baby.

After crowning, the baby’s nose and mouth are suctioned. This is in order to remove fluids and mucus which protected the baby in the womb’s amniotic fluid. The nurse ensures that the umbilical cord is not strangling the baby. This stage ends with the birth of the child and the severance of the umbilical cord.

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Labor and Delivery Nursing: A Case Study

Tracy’s Second Stage

Tracy spent two and a half hours in this stage. The baby flexed so that it was facing the right side of Tracy’s pelvic bone. The contractions were close to each other, and the nurses encouraged the patient to push with every contraction.

Morphine was administered intravenously. This was to ease the patient’s pain, because she had not been medicated at the first stage. Periodic heart rates of the infant were taken. When the intravenous was started, the fetal heart rate strip showed a deceleration. It then recovered to baseline. It was fluctuating between100-120. An episiotomy was conducted. This is because Tracy’s vagina was a bit narrow.

The baby’s noses and mouth were suctioned just after crowning. This was to ensure that the airways were open and clear of any obstruction. A quick check assured the nurses that the umbilical cord was not strangling the baby.

Shortly afterwards, a healthy baby boy was born. It weighed 5lbs 11 oz. it was twenty inches long. The nurses administered narcan to the boy. This was in order to counter the effects of the morphine. The temperature of the boy was taken. It was taken rectally because

Third Stage of Labor

This stage involves the delivery of the placenta. After birth of the baby, the nurse will examine the mother for any signs of tears to the perineum (Hosster, 2009). Any tears will be repaired. The pain sensitivity of the perineum will also be determined. The area is usually numb after delivery. But there are cases where it still pains even if the mother was under pain medication.

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Labor and Delivery Nursing: A Case Study

In this case, a local anesthetic is administered to numb it. In cases where episiotomy had been conducted, it will be stitched at this stage.

The placenta starts to separate five or ten minutes after the baby is born. There are several signs to indicate that the placenta is separating. The first is presence of blood at the vagina. This blood originates from the injuries that the placenta is leaving behind on the uterine wall as it tears away (Glazernh, 2009). The second sign is the lengthening of the umbilical cord. The cord lengthens as it is pushed out by the muscles. During this expulsion, it takes the flak of the separating placenta. There is also change in the shape of the uterus. This is another indication that the placenta is separating. The uterine shape changes as the muscles contract to push out the placenta. It also changes as the placenta leaves the uterus, considering the fact that it was occupying a large space.

The mother can be assisted to deliver the umbilical cord. This is done by tugging gently on the umbilical cord. It can also be done by pressing down on the uterus. The mother experiences contractions of the uterus wall. This occurs as the walls clumps down in an effort to stem lose of blood (Parsons, 2008).

Tracy’s Third Stage

The patient had an extraordinarily big placenta. After delivery, checks were carried out to determine whether there were any tears to the perineum, apart from the episiotomy. It was noted that there were in fact several minor tears, which occurred before the pressure was relieved by episiotomy. These were repaired by the nurse, together with the episiotomy. Tracy’s perineum was not numb, and she was complaining of pain. To help her, a local anesthetic was administered.

The placenta started to separate after nine minutes. This was indicated by some blood at the

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Labor and Delivery Nursing: A Case Study

vagina. The patient was assisted by having to tug gently at the umbilical cord. There was heavy bleeding, and at some point the orderlies were contemplating transfusion regardless of Tracy’s vehement objection. But the bleed stopped itself. The placenta was delivered after twenty one minutes. She lost 750 mL of blood.

Fourth Stage

This takes sixty minutes after the placenta is delivered. This is when the uterus begins to return to its normal size and shape (Parsons, 2008). There is bleeding that is experienced at this stage. There is close monitoring of the patient. This is to ensure that she recovers from delivery. Due to the bleeding, there is the need to monitor the patient’s blood pressure and its intensity. The size of the uterus is also checked. This is carried out for about six or ten hours.

Tracy’s Fourth Stage

Tracy experienced steady leak of blood, though it was not heavy. But her recovery from delivery was successful. Her pulse and blood pressure were normal. She was under close monitoring for about eight hours.

This is also the stage where the mother and the child establish their bonding. Tracy was given the child to breastfeed. The boy was alert and calm. Breastfeeding is one of the bonding mechanisms between the two, together with touching and holding.

Conclusion

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Labor and Delivery Nursing: A Case Study

The writer’s experience in L&D department was both challenging and informative. It provided the writer with first hand experience of what to expect when in an actual working environment. The knowledge of the writer was expanded beyond that of text book and theoretical scenarios. The writer was able to interact with other nurses in the wards, and as such, team work value was instilled.

The writer performed several nursing measures while in this department. They included prepping the mothers on the best techniques to reduce their pain during labor. The writer was also involved in preparing medications for the patients. They included intravenous and also other forms of medications. Another activity was the assembly of the intravenous rig and inserting it to the patient.

There was also involvement in the deliver itself. Under the supervision of the head nurse, the writer was able to deliver a baby on their own. There was also performance of episiotomy, like in Tracy’s case. Most of the times, the writer was involved in the monitoring and documentation of the progress of labor, for both the mother and the fetus.

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Labor and Delivery Nursing: A Case Study

References

Glazernh, J. L. (2009). A handbook for today’s midwife. 3rd ed. Chicago: University Press, 534-535.

Hosster, S. B. (2009). Labor and Delivery: A guide for first mothers. New Jersey: Prentice Hall, 78.

Murdaugh, D. L. (2008). “Importance of teamwork in labor and delivery.” Baby Center Advisory, 12

th

March, 2008. 34.

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Labor and Delivery Nursing: A Case Study

Parsons, I. O. (2008). Stages of labor. 4th ed. New York: McGraw-Hill, 234.

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