GROUP 1: CASTILLO, JESSICA JANE 2BSN-B

DE GUZMAN, CAMERON JOSH B.

DESEO, CHARLENE MAE A.

Now, try some big leap.

RLE Activity 2: Care Plan Critical Thinking Activities: Alterations in Normal Labor

Keep going.
Case Scenario
Sharry, a 16-years old primigravida at 43 weeks of gestation with a height of 5’3 enters
the hospital. She stated that her LMP was July 14, 2020 so her EDD would be April 20, 2021.
Upon performing IE you noticed a ruptured membrane and the bag of water breaks at 6cm cervix
dilation. Her labor is being stimulated with oxytocin administered IV. Her contractions have been
increasing in intensity with a frequency of every 2 to 2 ½ minutes and a duration of 80 to 85
seconds. She is currently in supine position with a 30-degree elevation of her head.

After performing Internal Examinaton, the cervix dilated at 9cm. On observation of the
monitor tracing, you note that during the last 2 contractions the FHR decreased after the contraction
peaked and did not return to baseline until about 10 seconds into the rest period. A slight decrease
in variability and baseline rate was observed.
She stated that “Napansin ko na napapadalas ang paghilab ng tiyan ko at nararamdaman kong
malapit na lumabas ang baby ko.”

Vital signs taken as follows: BP: 90/70 mmHg T: 37°C HR: 105 bpm RR: 21 bpm FHR: 86 bpm
Cervix: 9cm dilated, Fetal presentation: cephalic presentation (complete flexion),

a. Identify the pattern described and the possible factors responsible for it.

Progressing Contractions. Contractions that are lasting longer and getting closer together
are considered to be progressing. Over the course of labor, contractions get longer, stronger
and closer together.
✓ Contractions have been increasing in intensity with a frequency of every 2 to 2 ½
minutes and a duration of 80 to 85 seconds.
✓ During the last 2 contractions the FHR decreased after the contraction peaked and
did not return to baseline until about 10 seconds into the rest period.
✓ A slight decrease in variability and baseline rate was observed.

Possible Factors

▪ Oxytocin administration IV
The induction or continuance of labor with oxytocin should be avoided when the following
conditions or situations are present: evidence of fetal distress, fetal prematurity, abnormal fetal
position (including unengaged head), placenta previa, uterine prolapse, vasa previa, cephalopelvic
disproportion, cervical cancer, grand multiparity, previous surgery of the uterus or cervix
(including 2 or more cesarean deliveries), active genital herpes infection, or in any condition
presenting as an obstetric emergency requiring surgical intervention. Use of oxytocin in any of
these settings can aggravate the condition or cause unnecessary fetal or maternal distress.

If the contractions last longer than 60 seconds, slow or stop the oxytocin. If the contractions
consistently occur more often than every 2 minutes, slow or stop the oxytocin. If the patient
experiences uterine tetany (continuous contractions), stop the oxytocin.

b. Describe the actions you would take. State the rationale for each action.

Observe the Fetal Response

The nurse remains alert for FHR patterns that suggest reduced placental exchange
secondary to excessive UA. Examples are fetal bradycardia, tachycardia, pathologic decelerations,
and decreased FHR variability. The nurse should assess the woman and fetus carefully to identify
the most likely cause of the problem and institute corrective actions

▪ Stop the oxytocin infusion and administer a bolus of at least 500 mL of the primary nonadditive
infusion.
▪ Keep the woman in a side-lying position to prevent aorto-caval compression and increase
placental blood flow.
▪ Consider oxygen administration at 10 L/min via nonrebreather facemask until FHR pattern
improves.
▪ Notify the provider; anticipate order for terbutaline (Brethine), a smooth muscle relaxant, 0.25
mg subcutaneously, if no improvement with other interventions.
▪ Oxytocin may be restarted when the tachysystole resolves and the FHR pattern returns to
normal. The oxytocin should be restarted at no more than half the previous rate if it has been
turned off for less than 20 to 30 minutes. If more than 30 to 40 minutes have elapsed, it should
be restarted at the initial dose.
Observe the Mother’s Response
▪ The uterus must be assessed for excessive UA that may reduce fetal oxygenation and contribute
to uterine rupture.
▪ If the oxytocin must be discontinued, the medical decision about resuming is individualized.
▪ The woman's blood pressure and pulse rate are taken every 30 minutes or with each oxytocin
dose increase to identify changes from her baseline. Her temperature is assessed every 2 hours,
unless ruptured, and then it is assessed hourly to identify infection.
▪ The woman may need to use pharmacologic and nonpharmacologic pain management
techniques sooner than in a spontaneous labor.
▪ Recording intake and output identifies fluid retention. which may precede water intoxication.

▪ After birth, the mother is observed for postpartum hemorrhage caused by uterine relaxation.

c. Make a nursing care plan. (Identify at least 2 nursing diagnoses)

Nursing Care Plan:
Fill in the appropriate elements of the care plan for this client.
 ASSESSMENT
PLANNING

NURSING EVALUATION
DIAGNOSIS
GOAL / EXPECTED
NURSING INTERVENTIONS RATIONALE
OUTCOME

Subjective: Risk for maternal Client will Independent:

16 years old’ injury in relation develop/maintain a 1.Review prenatal record for 1.Provides information Goal met, patient
with post-maturity good labor pattern; history of previous needed in formulating Developed and
“Napansin ko na contractions 2–3 min pregnancies and outcomes, plan of care. Alerts nurse maintain a good
napapadalas ang apart, lasting 40–50 prenatal laboratory studies, to the possibility of labor pattern
paghilab ng tiyan ko sec, with uterine pelvic measurements, existing or developing contractions.
at nararamdaman relaxation to normal allergies, weight gain, vital problem
kong malapit na tone between signs, last menstrual period,
lumabas ang baby ko” contractions. and EDB.
Goal met, patient
Objective: Patient will have completed her
*Primigravida at 43 accomplish cervix 2.Review the history of labor, 2.Helpful in identifying cervical dilation
weeks of gestation dilation at least 1 onset, and duration. possible causes, needed properly without
cm/hr for primipara, diagnostic studies, and complication
*Contractions in active phase, with appropriate interventions.
Frequency: 2 to 2 ½ fetal descent at least 1 Uterine dysfunction may
minutes cm/hr for primipara. be caused by an atonic or
a hypertonic state. Uterine Goal met,
Duration: 80 to 85 Client will accomplish atony is classified as accomplish safe
seconds delivery without primary when it occurs normal delivery
complications. before the onset of labor without
BOW: breaks at 6cm (latent phase) or complications
cervix dilation secondary when it occurs
after well-established
*Vital signs take as labor (active phase).
follows:
BP: 90/70
T: 37 3.A rigid or unripe cervix
HR: 105 3. Note the condition of will not dilate, impending
RR: 21 cervix. Monitor for signs of fetal descent/labor
FHR: 86 amnionitis. Note elevated progress. Development of
Cervix: 9cm dilated temperature or WBC; odor amnionitis is directly
Fetal presentation: and color of vaginal related to length of labor,
cephalic presentation discharge. so that delivery should
(complete flexion) occur within 24 hr after
rupture of membranes.

4.Assess uterine contractile 4.Dysfunctional

pattern manually (palpation) contractions lengthen
or electronically via external, labor increasing the risk
or internal monitor with of maternal/fetal
internal uterine pressure complications. A
catheter (IUPC). hypotonic pattern is
reflected by frequent, mild
contractions measuring
 less than 30 mm Hg via
IUPC or “soft as chin”
per palpation. A
hypertonic pattern is
reflected by increased
frequency, an elevated
resting tone per palpation
or greater than 15 mm Hg
via IUPC, and possibly
decreased intensity of
contractions. Note:
Intensity of contractions
cannot be measured by an
external monitor.
5. Evaluate the current level
of fatigue, as well as activity 5. Excess maternal
and rest prior to onset of exhaustion contributes to
labor. secondary dysfunction, or
may be the result of
prolonged labor/false
labor.
6. Note effacement, fetal
station, and fetal 6. These indicators of
presentation. labor progress may
identify a contributing
cause of prolonged labor.
For example, breech
presentation is not as
effective a wedge for
cervical dilation as is
vertex presentation.

7. Prepare client for 7. Rupture of membranes

amniotomy, and assist with relieves uterine
the procedure, when the overdistension (a cause of
cervix is 3–4 cm dilated. both primary and
secondary dysfunction)
and allows presenting part
to engage and labor to
progress in the absence of
cephalopelvic
disproportion (CPD).
Note: Active management
of labor (AML) protocols
may support amniotomy
once presenting part is
engaged to accelerate
labor/help prevent
dystocia.

8. Provide perineal care, as

indicated. Monitor 8. Reduces risk of
temperature every 2 hr. Note infection and/or provides
color and odor of vaginal early detection of
drainage. developing infection.
Presence of meconium
 staining indicates fetal
Dependent: distress.

9. Assist with application of

prostaglandin preparations. 9. Facilitates cervical
ripening; may stimulate
labor and/or enhance
effectiveness of oxytocin
infusion.

10. Start primary IV line with 10. Large-gauge catheter

large-gauge indwelling is preferred in case of the
catheter. need for surgical
intervention, blood
transfusion, or emergency
fluid/drug administration.

11. Discontinue oxytocin, as 11. Hyperstimulation of

indicated, and increase the uterus (intrauterine
infusion of plain IV solution. pressure greater than 75
Notify physician. mm Hg) can lead to
abruptio placentae, uterine
tetany, and possible
rupture.

12. Administer 1–2 g MgSO4 12. Although the

slowly, as necessary, or circulatory half-life of
terbutaline (Brethaire) oxytocin is 3–9 min,
subcutaneously (SQ). uterine activity from
effects of oxytocin
administration may last
20–30 min after infusion
is stopped. MgSO4 or
terbutaline may be
indicated to relieve
oxytocin-induced uterine
tetany.
 PLANNING

ASSESSMENT EVALUATION
NURSING DIAGNOSIS
GOAL / EXPECTED NURSING
RATIONALE
OUTCOME INTERVENTIONS

Subjective: Risk for decreased *After 8 hours of Independent: Goal met after 8
16 years old’ cardiac output related to nursing 1. Assess the patient’s1. To determine presence hours of nursing
decreased venous return interventions, client general physical of abnormality. interventions,
“Napansin ko na and as evidenced by will display FHR condition. client was able to
napapadalas ang hypotension within normal limits. display FHR within
paghilab ng tiyan ko 2. Note presence and 2. Excess fluid retention normal limits.
at nararamdaman *After 8 hours of extent of edema. Monitor
places the client at risk for
kong malapit na nursing FHR during and between circulatory changes, with Goal met after 8
lumabas ang baby ko” interventions, client contractions. possible uteroplacental hours of nursing
will maintain vital insufficiency manifested interventions,
Objective: signs appropriate for as late decelerations. client was able to
*Primigravida at 43 stage of labor, free maintain vital signs
weeks of gestation of pathological 3. Assess BP and pulse 3. Increased resistance to appropriate for
edema and excessive between contractions, as cardiac output can occur if stage of labor, free
*Contractions albuminuria. indicated. Note abnormal
intrapartal hypertension of pathological
Frequency: 2 to 2 ½ readings. develops, further elevating edema and
minutes blood pressure. excessive
albuminuria.
Duration: 80 to 85 4. Note any hypertensive 4. Oxytocin increases
seconds responses to oxytocin cardiac circulating volume
administration. (sodium and water
BOW: breaks at 6cm absorption) and cardiac
cervix dilation output and may also
increase BP and pulse.
*Vital signs take as
follows: 5. Monitor BP and pulse 5. Analgesics relax
BP: 90/70 per protocol or smooth muscles within the
T: 37 continually if hypotension blood vessels, reducing
HR: 105 is severe after resistance to cardiac
RR: 21 administration of output and lowering BP
FHR: 86 analgesia. and pulse.
Cervix: 9cm dilated
Fetal presentation: 6. Accurately record 6. Bedrest promotes
cephalic presentation parenteral/oral intake, and increases in cardiac and
(complete flexion) output. Measure specific urine output with a
gravity if kidney function corresponding decrease in
is decreased. urine specific gravity. An
elevation of specific
gravity and/or reduction in
urine output suggests
dehydration or possibly
developing hypertension.

7. Keep the woman in a 7. To prevent aortocaval

side-lying position compression (Venacaval
syndrome)
and increase placental
blood flow.
Dependent:

8. Test urine for albumin. 8.Levels greater than 12

Report levels above 12. indicate kidney
involvement; levels 11 or
lower may be due to
muscle catabolism
occurring with activity
(contraction) or to
increased metabolism in
the intrapartal period

9. Hyperstimulation of
9. Stop the oxytocin the uterus (intrauterine
infusion and administer pressure greater than 75
bolus of at least 500 mL mm Hg) can lead to
of the primary abruptio placentae, uterine
nonadditive tetany, and possible
Infusion rupture.

10. To improve fetal heart

10. Consider oxygen rate.
administration at 10
L/min via nonrebreather
face mask until FHR
pattern
improves.
 ASSESSMENT
PLANNING

EVALUATION
NURSING DIAGNOSIS
GOAL / EXPECTED NURSING
RATIONALE
OUTCOME INTERVENTIONS

Subjective: Risk for fetal Injury Patient will Independent: Goal met, patient
16 years old’ related to prolonged participate in 1. Assess FHR manually 1. Detects abnormal participated in
labor and as evidenced interventions to or electronically. Note responses, such as interventions, the
“Napansin ko na by decreased in fetal improve labor variability, periodic exaggerated variability, labor pattern
napapadalas ang heart rate. pattern and reduce changes, and baseline bradycardia, and improved and
paghilab ng tiyan ko identified risk rate. If in the free tachycardia, which may reduced the
at nararamdaman factors and also the standing birth center, be caused by stress, identified risk
kong malapit na patient will display check Fetal heart tone hypoxia, acidosis, or factors also the
lumabas ang baby ko” FHR within normal between contractions sepsis. patient display
limits , with good using a Doptone. Count normal FHR in
Objective: variability, no late for 10 min, break for 5 normal limits, with
*Primigravida at 43 decelerations noted. min, and count again for good variability,
weeks of gestation 10 min. Continue this and no late
pattern throughout the decelerations
*Contractions contraction to midway noted.
Frequency: 2 to 2 ½ between it and the
minutes following contraction.

Duration: 80 to 85 2. Note frequency of 2. Contractions occurring

seconds uterine contractions. every 2 min or less do not
Notify physician if the allow for adequate
BOW: breaks at 6cm frequency is 2 min or less. oxygenation of
cervix dilation intervillous spaces.

*Vital signs take as 3. Resting pressure greater

follows: 3.Note uterine pressures than 30 mm Hg or
BP: 90/70 during resting and contractile pressure
T: 37 contractile phases via greater than 50 mm Hg
HR: 105 intrauterine pressure reduces or compromises
RR: 21 catheter, if available. oxygenation within
FHR: 86 intervillous spaces.
Cervix: 9cm dilated
Fetal presentation: 4. Identify maternal 4. Sometimes, simple
cephalic presentation factors such as procedures (such as
(complete flexion) dehydration, acidosis, turning client to lateral
anxiety, or vena caval recumbent position) can
syndrome. increase circulating blood
and oxygen to uterus and
placenta and may prevent
or correct fetal hypoxia.

5. Monitor fetal descent 5. Descent that is less than

in birth canal in relation 1 cm/hr for a primipara, or
to ischial spines less than 2 cm/hr for a
multipara, may indicate
CPD or malposition

6.Note color and amount 6.Excess amniotic fluid

of amniotic fluid when causing uterine
membranes rupture. overdistention is
 associated with fetal
anomalies. Meconium-
stained amniotic fluid in a
vertex presentation results
from hypoxia, which
causes vagal stimulation
and relaxation of the anal
sphincter. Noting
characteristics of amniotic
fluid alerts staff to
potential needs of
newborn, e.g.,
airway/ventilatory
support.

7.Observe for visible cord 7.Cord prolapse is more

prolapse when likely to occur in breech
membranes rupture, and presentation, because the
occult cord prolapse as presenting part is not
indicated by variable firmly engaged, nor is it
decelerations on monitor totally blocking the os, as
strip, especially if fetus is in vertex presentation.
in breech presentation.

8.Note odor and change 8.Ascending infection and

in color of amniotic fluid sepsis with accompanying
with prolonged rupture of fetal tachycardia may
membranes. occur with prolonged
rupture of membranes.

Dependent:

9.Prepare client for the 9. Such presentations

most expedient method of increase the risk of CPD,
delivery if fetus is in owing to a larger diameter
brow, face, or chin of the fetal skull entering
presentation. the pelvis (11 cm in brow
or face presentation, 13
cm in chin presentation,
versus 9.5 cm for vertex
presentation), often
necessitating assisted
delivery via forceps or
vacuum, or cesarean
delivery because of failure
to progress and ineffective
labor pattern.

10. Arrange transfer to 10. Risk of fetal/neonatal

accurate care setting if injury or demise increases
malposition is detected in with vaginal delivery if
client in a free-standing presentation is other than
birth center without vertex.
adequate surgical/high-
risk neonatal capabilities

11.Administer antibiotic 11.Prevents/treats

to client, as indicated. ascending infection and
will protect fetus as well.

12. Prepare for cesarean 12. Vaginal delivery of an

delivery of breech infant in breech position is
presentation if fetus fails associated with injury to
to descend, labor progress the fetal spinal column,
ceases, or CPD is brachial plexus, clavicle,
identified. and brain structures,
increasing neonatal
mortality and morbidity.
Risk of hypoxia caused by
prolonged vagal
stimulation with head
compression, and trauma
such as intracranial
hemorrhage, can be
alleviated or prevented if
CPD is identified and
surgical intervention
follows immediately