Primagravida Female, 28

Primagravida Female, 28

1. Antepartum

   • admission report
     • SROM
     • contracts every 2 minutes
     • 3 cm dialated, 50% effaced

2. Medical Hx

   • labs/diagnostics
     • positive for herpes
       • treated 2 weeks prior
     • unknown Group B strep
     • A+ Blood
   • risk factors
     • unknown rupture of membranes
       • meconium?
     • lack of support system
       • father of child deployed
   • G1P0
     • G(1)T(0)P(0)A(0)L(0)

3. 1st stage

   • Assessment
     • reports pain 10/10
       • given epidural analgesia
         • Foley catheter inserted
     • severe nausea present
       • risk for fluid loss
     • FHR Variability
       • fetus stable
       • external fetal monitoring used
     • initially presenting in OT position
   • 1-10cm
   • interventions
     • meds
       • fentanyl
       • reglan
       • zofran
       • ancef
     • nonpharmacological
       • cold rag
       • heated blankets

4. 2nd stage

   • 10cm to child delivery
   • Assessment
     • position
       • turned to cephalic vertex
       • 10 cm
         • 100% effacement
     • nausea increased
     • correct pushing technique
   • Interventions
     • head presenting to HCP
       • Midline episiotomy
         • 2nd degree
           • 2 dissolvable sutures
         • risk for infection
     • nonpharmaceutical
       • psychosocial support
       • encouragement
     • meds
       • pitocin hung
       • other meds continued

5. 3rd stage

   • assessment
     • nausea no longer present
     • fundus firm and palpable
     • placenta delivered unassisted
       • intact
       • cultures taken
         • risk for infection
   • interventions
     • medications
       • pitocin
       • all others dc
       • pain medications
         • ibuprofen
         • hydrocodone

6. Post-Partum

   • risks
     • hemorrage
       • boggy fundus
       • >1 pad per hour
     • infection
       • fever >100.4F
   • interventions
     • fundal massage
     • education
       • childcare
         • breastfeeding
         • resources
       • recovery
         • <1 pad/hour
           • normal lochia stages
         • hygiene
           • peribottle
           • tucks pads
     • medications
       • pain

7. Neonate

   • Assessment
     • fetal assessment
       • AGA
         • 38.4 weeks
       • FHR variability
     • neonatal assessment
       • APGAR
         • 8 at 1 minute
         • 9 at 5 minutes
       • female
         • 2973 grams
           • 17 inches
       • risk for infection
   • interventions
     • nutrition
       • EBF
         • Latched on <1 hour PP
     • tactile stimulation
       • mouth and nasal suctioning