Normal labor - Nursing Case Study

Pathophysiology

• Primary mechanism: Hormonal signaling - Labor begins when the levels of progesterone decrease and levels of oxytocin and prostaglandins increase. This hormonal change triggers the uterus to contract and the cervix to dilate and efface (thin out), preparing for baby's passage through the birth canal.

• Secondary mechanism: Uterine contractions - Regular, rhythmic contractions of the uterus are the body's way of moving the baby down and out of the uterus. Contractions cause the cervix to dilate and efface, which is necessary for the baby to pass into the birth canal.

• Key complication: Dystocia - This is a common labor complication characterized by slow and difficult labor or childbirth. It can be caused by various factors, such as the baby’s position, size, or the mother's pelvis size or shape. It can lead to fetal distress and may require medical intervention like a cesarean section.

Patient Profile

Demographics:

28 years old, Female, School teacher

History:

• Key past medical history: No significant past medical history; previous uncomplicated pregnancy with vaginal delivery two years ago

• Current medications: Prenatal vitamins

• Allergies: No known drug allergies

Current Presentation:

• Chief complaint: Regular contractions, 10 minutes apart

• Key symptoms: Mild lower back pain, contractions, water broke

• Vital signs: Blood pressure - 120/80 mmHg, Pulse - 80 beats per minute, Respiratory rate - 16 breaths per minute, Temperature - 98.6 F.

Section 1

Initial Assessment Findings:

Upon physical examination, the patient is found to be in the early stages of labor with a cervical dilation of 3 cm and 50% effacement. The fetal heart rate is 140 beats per minute which is within the normal range. The patient's pain level is rated as a 3 on a scale of 1 to 10, which is manageable for her at this point. The baby is positioned head down, which is optimal for a vaginal delivery. However, the slow progression of cervical dilation and effacement is suggestive of possible dystocia, which is a concern given the previous uneventful delivery.

The patient is encouraged to walk around to help speed up labor progression and to change positions frequently to help cope with the pain. The nurse also advises the patient to stay hydrated and provides her with a birthing ball to help alleviate back pain. The patient is aware of the possibility of dystocia and understands the potential need for medical intervention. She expresses a preference for a vaginal delivery but agrees to follow the advice of her healthcare team for the safety of her and her baby.

The nurse will continue to monitor the patient's vital signs, the baby's heart rate, and the progression of labor. The nurse will also reassess the patient's pain level and coping mechanisms frequently. This continuous assessment will allow the nurse to identify any changes that may indicate a worsening of dystocia and to intervene promptly.

Section 2

Change in Patient Status:

After several hours of observation, the patient's labor has progressed slowly. Her cervical dilation has only increased to 4 cm with 60% effacement. She rates her pain level as a 7 on a scale of 1 to 10, which is significantly higher than earlier. The baby's heart rate remains stable at 140 beats per minute. However, the patient begins to experience irregular contractions, which are less effective in facilitating the dilation and effacement of the cervix. She expresses feeling fatigued and her anxiety level appears to have increased.

The irregular contractions and slow progression of labor suggest that the patient may be experiencing dystocia. The nurse reassures the patient and explains that this is a relatively common complication that can be addressed by her healthcare team. The nurse encourages the patient to continue changing positions, staying hydrated, and using the birthing ball for pain relief. The nurse has also contacted the patient's obstetrician to discuss the possibility of implementing medical interventions to assist with labor progression. The focus remains on ensuring the safety and wellbeing of both the patient and her baby.

Section 3

Initial Assessment Findings:

The nurse conducts a thorough assessment to evaluate the patient's current status. She notes that the patient's blood pressure is slightly elevated at 135/85 mmHg, but her pulse rate remains stable at 85 beats per minute. Her respiratory rate is 20 breaths per minute and her temperature is 98.6 degrees Fahrenheit, both within normal ranges. On palpation, the nurse observes that the patient's contractions are indeed irregular, varying in intensity and frequency. The fundal height measurement corresponds to the gestational age, indicating that the baby is growing at a healthy rate.

The nurse also assesses the patient's emotional state. She notes that the patient appears increasingly anxious and distressed due to the slow progression of labor and the ensuing fatigue. The patient verbalizes her fear of a prolonged labor and the potential need for a Caesarean section. The nurse provides emotional support and reassures the patient that her healthcare team is doing everything possible to ensure a safe and healthy delivery. The nurse's assessment findings will be shared with the healthcare team to guide the development of an updated plan of care. This will focus on managing the patient's pain and anxiety, facilitating labor progression, and monitoring the baby's wellbeing.

Section 4

Following a consultation with the healthcare team, the nurse implements an updated plan of care based on her assessment findings. The plan focuses on alleviating the patient's anxiety and managing her pain. A non-pharmacological approach is initially taken to manage the patient's pain and includes strategies such as controlled breathing exercises, use of a birthing ball, and encouraging position changes to aid in the progression of labor. The nurse explains the interventions to the patient, who appears receptive and willing to participate.

After a couple of hours, the nurse reassesses the patient's status. Her blood pressure has lowered slightly to 130/80 mmHg, and her pulse rate remains stable at 85 beats per minute. Her respiratory rate is consistent at 20 breaths per minute. The patient reports a decrease in her anxiety levels and states that the pain is more manageable, thanking the nurse for her support. However, upon examination, the patient's contractions are still irregular, and labor doesn't seem to be progressing as quickly as expected. The nurse documents these findings and communicates them to the healthcare team, discussing potential next steps and interventions to facilitate labor progression.

Section 5

In response to the patient's stalled labor progression, the healthcare team decides to administer a low dose of Pitocin to augment the labor. The nurse carefully explains the procedure and potential side effects to the patient, who gives her consent. The intravenous Pitocin is started at 1 milliunit per minute and is scheduled to be increased gradually every 30 minutes, as tolerated.

After an hour, the nurse assesses the patient's response to the intervention. She notes that the patient's contractions have become more regular, occurring every 3 to 5 minutes, and have increased in intensity. The patient reports her pain level has increased to a 6 on a scale of 0-10. The nurse validates the patient's pain and reassures her that this is a normal response to the medication. The nurse continues to support the patient with controlled breathing exercises and position changes to manage the pain. The patient's vital signs remain stable, with a blood pressure of 132/85 mmHg, pulse rate of 88 beats per minute, and respiratory rate of 20 breaths per minute. The nurse documents these findings and plans to reassess the patient's status and progression of labor in another hour.