LABOR & DELIVERY WORKSHEET

Client ---- Age 27 G3 T1 P0 A1 L1 LMP 01/20/12 EDC 10/28/12 by Ultrasound or Dates Obstetrician Hage MD, Samir Support Person Husband EFA 39.0 Prepared Childbirth Class Not attended Date/Time To Hospital 10/22/12 0600 Admitting Diagnosis: Scheduled CS ASSESSMENT HT 56 WT 234 Hgb/Hct 12.5/39.3 Rh/Type A+ Coombs Negative VDRL Negative GC Negative Chlam Negative BetaStrep Positive (no antibiotics given d/t CS delivery) Last PAP 1 yr ago. MEDICATIONS Heartburn med 1TAB PO PRN (Home-pt states not knowing name of med) PNV 1TAB PO Daily Percocet PRN given for pain relief Allergies: Vicodin Exam/Procedures: Scheduled CS (0730) Comfort Measures: Semi-fowlers. Pt stated having pain/cramping on lower abd. (pain rated at 4 on a 0-10 pain scale). Pt allergic to Vicodin. Percocet given instead for pain relief. Anesthesia given-spinal. HIGH RISK FACTORS Risk for bleeding r/t scheduled abdominal surgery (CS) Risk for disturbed body image r/t past experience on last CS (resulted on a bad scar) Pt has asthma, anxiety may increase respirations (possible asthmatic episode) Last Ultrasound Info: Confirmed EDC and fetal-well being TREATMENTS IV R ARM. Lactated ringer. Diet: NPO (last fluids 10/21/12 2100, last solids 10/21/12 2000) Void: Ad lib (able to ambulate to restroom with or without assistance) Foley catheter placed by student nurse before surgery BM: No BM during shift Emesis: None. Patient stated feeling nauseous and wanting to vomit during surgery (pan placed against head) Activity: Able to ambulate to restroom Comments: Pt is placed on semi-fowlers. Pt is Caucasian. Religion: CH, no cultural needs. Labor Assessment Date/Time Start of Labor 10/22/12 (0745 start of CS) Contractions: N Interval N/A Duration N/A Intensity Mild Membranes Intact (AROM during surgery) Fluid N/A SVE: dilation N/A effacement N/A station N/A FHR: 135 bpm FM: Present, active Fetal monitor: FSE N Toco Y Variability Moderate (16-25) Reassuring: Y (Decels absent, present accels) Scheduled CS DELIVERY Date 10/22/12 Time 0754 Sex F NSVD/Vacuum/Forceps/CS APGAR: 1 min 9 5 min 9 10 min N/A Cord Vesses: 3 Placenta: Manually removed/ complete Epis: None Lac: None Breastfeed: Y Support Person present: Y, Husband Infant Wt: 9 lbs 6.13 oz 4256 Grams Infant Length: 21 in 10 cm VitK: Given L thigh Eye Med: Given (erythromycin)

Comments: Incision-suture, bandaged. Pt stated she had a reaction to the bandage used on last cesarean. Paper based bandage used instead. Baby and mom transferred to PP, no complications. Mother in stable condition. Skin-to-skin. Baby latched onto breasts without complications. Nursing Dx #1: Risk for deficient fluid volume r/t active fluid volume loss (hemorrhage) s/t uterine rupture (repetitive C/S) aeb decreased BP and increased P Goal: Pt will maintain normal blood pressure, pulse, and body temperature within pts parameters during shift. Pt will report sudden pain and active blood loss to nurse during shift. Expected Outcome: Pt did not experience a hemorrhage d/t uterine rupture during shift. Pts BP and P were within pts parameters. Nursing Dx #2: Acute pain r/t abdominal incision s/t CS aeb pt states feeling an increase in pain (rates pain at 4 on 0-10 pain scale) and an increase pressure on her lower abdomen Goal: During shift, pt will describe nonpharmacological methods (repositioning, quiet environment) that can be used to help achieve comfort-function goal and will verbalize a relief of pain. Expected Outcome: Pt reported a relief of pain and rated pain at 2 on a 0-10 pain scale during shift. Nursing Dx #3: Disturbed body image r/t surgery (CS) s/t labor and delivery process aeb pt states being worried about the appearance of the scar and how she will look after the surgery (pt stated that she had a bad scar from the previous CS) Goal: Pt will demonstrate adaptation to changes in physical appearance or body function d/t surgery as evidenced by adjustment to body change during shift and follow up appointments. Expected Outcome: Pt stated being satisfied with surgery and outcome of surgery (body). Pt stated that she is glad that the bad scar was removed from her previous surgery and has a new scar.

Progression of Labor
Time Dilation Effacement Station Frequency FHR (I) (E) Reassuring Non-Reassuring BP N/A scheduled CS CS (0745) Pulse Resp Temp

Recovery
Time BP 0930 126/86 0945 122/84 0950 122/82 Transferred to PP Pulse 80 76 80 Respiration 16 16 17 Temperature Fundus location Lochia 36.7 Midline, under umbilicus Moderate, rubra, clots present 36.5 Midline, under umbilicus Scant, rubra 36.4 Midline, under umbilicus ( 3cm) Scant, rubra

Client/Family Education:
Assessed patient for pain and on knowledge of CS. Pt stated being allergic to Vicodin. Percocet will be given for pain relief. Pt appeared calm and not anxious before surgery. Pt has had one past cesarean (2010). Pt verbalized reason for why a repeated cesarean is necessary (possible uterine rupture if vag. delivery). Pt did not attend childbirth classes. Pt educated by nurse about CS (pain process, epidural-position for administration-back curled, complications-bleeding, infection). Scheduled CS 0745 with no complications. Baby placed skin to skin with mom and dad. Mother breast-fed baby. Latching education not given at the time, baby latched immediately to breast. Education: Have pt ambulate as soon as possible (helps with healing process, relieves pain, helps relieve gas pain). Position changes to help stay comfortable. Educate on importance of incentive spirometer (to help lungs clear and stay active)

Nursing Interventions to promote mother infant attachment:

Skin to skin contact (baby and mother) immediately after CS. Mother breast-fed shortly after birth (after stable conditions confirmed). Assessed need for education on latching baby to breast. Education not needed at time. Baby latched on to breast with no problem. Mother was encouraged to breastfeed as much as possible d/t baby having low blood sugar. Babys blood sugar remained stable after breastfeeding (baby not sent to NICU). Nurse encouraged to have baby always at bed side by mom, skin to skin and breastfeeding as much as possible. Mother was educated on signs of infant hunger (lip smacking, sucking, bring hand to mouth, crying-late sign)

Parameters

2 2

1 min score 2

5 min score

<7 @ 5 min complete 10 min score

N/A

Heart rate

absent

<100

>100

2 Respiratory Effort Muscle tone Reflex Irritability

absent Slow Irregular Some flexion Good cry

N/A

2
Limp Active motion

2 2

N/A N/A

2
No Response Grimace Cry

1 Color Total
Pale Blue Extremities blue/ acrocyanosis All pink

N/A

N/A