1) Patient Introduction
Olivia Jones is a 23-year-old African-American female, G1P0 at 36 weeks of gestation. She has been diagnosed with severe preeclampsia and is admitted to the labor and delivery unit for assessment and surveillance.
Pregnancy has been unremarkable until routine prenatal visit at 30 weeks with elevated blood pressure at 146/92 mm Hg, proteinuria, and developing mild preeclampsia. She has been on bed rest at home until prenatal visit today with increasing symptoms, resulting in admission.
She has gained 3 pounds since prenatal visit 1 week ago. Protein dipstick is +4, negative ketones, negative glucose, +2 dependent edema, and facial puffiness.
Ms. Jones is complaining of a headache that is not resolved with acetaminophen. She presents with nausea and fatigue and complaining of epigastric pain, visual changes, and chest tightness. The fetus is active; however, patient states that it is a bit quieter than normal. There is a possibility of premature rupture of membranes. An IV with lactated Ringer’s is running at 125 mL/hr. Labs were obtained.
Medication: Magnesium sulfate (injection)
2 Patient Introduction
Brenda Patton is an 18-year-old Caucasian female, G1P0 at 38 2/7 weeks of gestation admitted to the labor and birthing unit for labor assessment.
The patient states that her water may have broken earlier this morning and she thinks she is in labor. AmniSure was positive. Vaginal exam reveals 50% effacement of cervix, cervical dilation 4 cm, and fetus at -2 station.
The patient’s boyfriend is present, and she has phoned her mother to inform her of her admission. The provider has been notified, and prenatal records have been pulled.
The lab report indicates that the patient’s group B strep vaginorectal culture taken at 36 weeks was positive. The patient wishes to have a natural birth without medication. Admission intrapartum orders have been initiated, initial labs have been drawn, and a saline lock has been placed in her forearm.
Medication: Promethazine hydrochloride
3 Patient Introduction
Amelia Sung is a 36-year-old Filipino female, G2P1 (L1) at 39 weeks of gestation, who was admitted 24 hours ago for induction of labor.
First-born male delivered vaginally 3 years and 3 months ago. Weight: 3,345 g (7 lb 6 oz). Length 55 cm (22 in).
She was started on oxytocin at 1 mL/1 mU, and the infusion was increased throughout the day per protocol. A mainline IV of lactated Ringer’s is running at 125 mL/hr, and oxytocin (30 units in 500 mL normal saline) is running at 20 mU/min (20 mL/hr).
Her cervical exam at admission was 2 cm dilation, 80% effaced, at -1 station, with fetus in vertex position. At 0100 hours, dilation was 4 cm, 100% effaced, still at -1 station and fetus in vertex position. She received an epidural shortly after that, and 1 hour later, her membranes ruptured; the fluid was clear.
Three hours ago, she was fully dilated and started pushing. The fetal heart rate has been stable with a baseline of 120/min, moderate variability, and early decelerations since she started pushing. She is getting tired from pushing, and the descent of the fetal head has been slow.
During the past few contractions, the baby has started to crown. The provider has been called and has arrived, so Amelia may continue pushing.
Medication: Oxytocin
4 Patient Introduction
Carla Hernandez is a 32-year-old Hispanic female, G2P1 (L1), at 39 5/7 weeks of gestation. She was admitted to labor and delivery in active labor at 0600 hours today, accompanied by her husband Earl.
To progress the delivery, artificial rupture of membranes was performed by the provider a few minutes ago. The provider has just left the room to make rounds.
Suddenly, the fetal heart rate drops dramatically, and you discover that the umbilical cord is prolapsed. You are ready to handle this situation with another nurse who is also present in the room.
Medication: Terbutaline sulfate
5 Patient Introduction
Fatime Sanogo is a 23-year-old primiparous female from Mali in her first hour after vaginal delivery. The patient was admitted yesterday at 0600 hours for oxytocin induction of labor secondary to postdates (41 4/7 weeks). She declined all pain medication during labor.
Following a prolonged second stage, she delivered a vigorous female infant at 0605 hours with Apgar scores of 9 and 9 and weight of 4,082 g (9 lb 0 oz). The patient contracted a second-degree perineal laceration during delivery; this has been repaired.
Placenta was delivered manually at 0635 hours via Dr. Schultz. Bleeding was controlled by fundal massage and infusion of remaining oxytocin induction bag, which is still running at 20 mL/hr (20 mU/min); approximately 100 mL left in the bag.
The patient was just up to the bathroom and couldn’t void. She is now dozing, and the father of the baby is at the bedside, holding the baby and sending text messages from the phone. Fatime does not speak English fluently, as she has only been in the country for 7 months. You enter the room to assume care of the patient and to perform the second of four assessments every 15 minutes.
Medication: Misoprostol