Case Overview: Bess Gaskill is a multiparous

Case Overview: Bess Gaskill is a multiparous woman with spontaneous rupture of membranes at 39 weeks gestation. She is being induced using Pitocin and is currently dilated to 9cm, 100% effaced and +1 station. She states she feels like she needs to push when having contractions Maternity: Labor Vital Signs: The patient is side-lying, current dilation is 10cm, 100% effaced, +1 station. External uterine and fetal monitors are in place. Contractions strong to palpation with soft resting tone. Patient remains on 9mu/min Pitocin IV. Patient states she feels the urge to push. Vital Signs: Temp 99.0 oral, HR 90, RR 24, BP – 130/82, Sats 99% on room air Patient Situation Update: You have Mrs. Gaskill “trial” pushing with the next 3 contractions. She pushes the fetus from a +1 station to +3, and states she feels a burning sensation in her perineum. The perineum is bulging slightly, and you observe a 5cm diameter circle of fetal head. You alert the provider that birth is imminent. *Use the data above and your knowledge of the second stage of labor, write a nursing note related to calling the healthcare provider to come for delivery and steps taken to prepare for the impending vaginal delivery NURSING NOTE: UPDATE: The physician arrives within minutes of calling. Mrs. Gaskill continues to push effectively and 15 minutes after beginning pushing, she has a spontaneous vaginal delivery of a male fetus. The baby weighs 8lbs 5oz (3900g), length is 54cm, head circumference is 34.2cm. His Apgar’s are 9 at 1 minute and 9 at 5 minutes. There were no complications with the delivery, but the pregnancy was complicated by a placental abruption. Mrs. Gaskill delivered 7 hours and 40 minutes after being admitted. Cord blood was collected and sent to the lab; results are pending. The placenta was intact and delivered spontaneously 15 minutes after the birth. The cord insertion was in the center of the placenta. What data in Mrs. Gaskill’s health record was relevant and/or concerning? What risk factors related to post-partum hemorrhage are present in Mrs. Gaskill’s health record. How would you prepare for this potential complication? What fetal heart rate pattern was evident on the monitoring strip? What nursing interventions are associated with this fetal heart rate pattern? What actions could you take if you encountered this fetal heart rate pattern and the patient was 5cm? SCIENCE HEALTH SCIENCE NURSING NUR 125

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