Pt.

Name: Denise Grace Lucero Age: 19 yrs old Gender: female

Physician: Dr. Gayle Gloria, MD Bed #: ROOM 457
Chief complaint: GI distress and abdominal Diagnosis: active labor
pain
VS: Lab results:
temp: 36.3
Bp: 120/80mmHg Chest x-ray - normal chest findings
Rr: 20cpm Complete blood count
Pr: 81bpm Blood type O+
SPO2: 98%
I&O: q shift
IVF: D5LR 1L
Cc/hr or gtts/min: Level:
120cc/hr
IVF Due: Pending labs: RAT, Urinalysis
Meds:
Start oxytocin drip
Give PLR 500cc fast drip while on left side lying position
Enoxaparin 40mg subcutaneous q24hrs
Nalbuphine 5mg IV q2hrs. PRN moderate pain or Acetaminophen 650mg PO q4hrs PRN
Aluminum and magnesium hydroxide 30ml PO q2hrs PRN for digestion
Metoclopromide 10mg IV q4hrs PRN for nausea and vomiting
Pitocin 6 mUnits/m; decrease dose to 4 mUnits when contraction progressed to 5-6cm dilation
Watch out for any unusualities, pls refer and facilitate lab works

- no allergies
- singleton vertex presentation
- 37 weeks AOG
- Primipara - a mother who will deliver for the first time
- no significant medical or surgical history
- taken prenatal vitamins ordered by OB

PALATTE 1 : ESTBLISH RAPPORT W/ CLIENT

Hi I am Daniela Francisco, your nurse for today. May I check for your wrist band maam? Please state your
full name and birth date please. Thank you. I’m gonna be assisting you today. I’m gonna close the doors
okay so that you won’t feel uncomfortable. What do you want me to call you ma’am? How are you doing
today, ma'am? So the first thing that I will do is check your vital signs okay?

Temp: 36.3
Bp: 120/80mmHg
Rr: 20cpm
Pr: 81bpm

- So maam if you don’t mind me asking, where is the father of the child?
- Does he know your current situation?
- are you still in school? What year?
- how about your friends? How is your relationship to them?
- how do you feel about having a child right now?
- how did your family take it when you announced to them that you are pregnant?
- did you ever think of using birth control?
Maam im gonna do a leopold maneuver okay? So that I know the fetal presentation of the baby. Then after
that, im gonna hook you to the electronic fetal machine.
- When did your abdominal pain started?
- Where did the pain start?
- how long is the pain?
- What were you doing before you feel the pain?
- On the scale of 0-10, 0 being no pain at at all and 10 as the worst pain possible, how would you rate the
pain you are feeling right now?
- is there something you do to alleviate the pain? What are those? did you try changing your position?

Now maam, I know you are nervous, you have a lot going on your mind right now, nut I assure you that I
will do my best to deliver the best care possible for you and your child. Do you have any questions?

PALATTE 2: ANSWERING PATIENT QUERIES RELATED TO LABOR AND DELIVERY MANAGEMENT

So now, im gonna brief you on what is going to happen during your labor and delivery okay?
Since you are still in 37 weeks, you are still on your pre term. I’m gonna brief you what would happen
during labor and delivery.

During labor, you will experience intense contraction with a frequency of 2-3 minutes apart, lasting about
40 seconds. But since you are in early labor you may experience braxton hicks contraction. It is a sign of
false labor, the contractions do not get closer, does not have a pattern and it stops when you move around
or change your position.

Then, if it is a true labor, your cervix will dilate from 3 cm to 7cm and your contractions will be stronger and
last longer.

There are also what we call as relaxation techniques to alleviate the contractions. You may breathe fully in
a slow rhythm. A foot massage can also to help to soothe you and decrease the edema or swelling in your
feet. Putting sacral pressure is also great to decrease lower back pain.

According to your chart, you are not experiencing vomiting so preeclampsia is less likely but possible to
happen. Preeclampsia is when your baby does not get enough blood and oxygen due to the placenta not
developing properly. It is characterized by having high BP, high amounts of protein in urine, head aches
and blurred vision.

We should also monitor if there is liquid gushing out of your vagina because it is may be the amniotic fluid
or urine. Amniotic fluid serves as the cushion for the growing fetus and facilitates water and nutrient
exchange between the mother and the fetus. If your water has broke, you should call a nurse or doctor
right away.

There are 4 stages of labor. During the first stage of labor, contractions help your cervix to thin and begin
to open. This is called effacement and dilation. As your cervix dilates, your health care provider will
measure the opening in centimeters. One centimeter is a little less than half an inch. During this stage, your
cervix will widen to about 10 centimeters. This first stage of labor usually lasts about 12 to 13 hours for a
first baby, and 7 to 8 hours for a second child.

The second stage of labor begins when the cervix is completely dilated (open), and ends with the birth of
your baby. Contractions push the baby down the birth canal, and you may feel intense pressure, similar to
an urge to have a bowel movement. Your health care provider may ask you to push with each contraction.
The contractions continue to be strong, but they may spread out a bit and give you time to rest. The length
of the second stage depends on whether or not you've given birth before and how many times, and the
position and size of the baby. The intensity at the end of the first stage of labor will continue in this pushing
phase. You may be irritable during a contraction and alternate between wanting to be touched and talked
to, and wanting to be left alone. It isn't unusual for a woman to grunt or moan when the contractions reach
their peak.

Third stage is After the birth of your baby, your uterus continues to contract to push out the placenta
(afterbirth). The placenta usually delivers about 5 to 15 minutes after the baby arrives.

And fourth stage, Your baby is born, the placenta has delivered, and you and your partner will probably
feel joy, relief, and fatigue. Most babies are ready to nurse within a short period after birth. Others wait a
little longer. If you are planning to breastfeed, we strongly encourage you to try to nurse as soon as
possible after your baby is born. Nursing right after birth will help your uterus to contract and will decrease
the amount of bleeding.

There was this intervention. We call it as the unang yakap. The moment after the baby comes out, you will
be able to touch and hug your baby. This promotes giving the baby warmth, love and safety.

Unang yakap includes the immediate and thorough drying of the baby (prevents hypothermia), promotes
skin to skin contact (establish bonding), properly timed cord clamping (prevents anemia and hemorrhage),
and the non separation of newborn and mom (early initiation of breastfeeding).

Health education for the new mother

Breathing Exercise During Labor - Inhale in nose release in mouth- This is very helpful to minimize
or ease the pain during labor.
And also, to relax your abdomen.

Ma’am try to relax - To lessen the tension, anxiety and relieve comfort during labor

Prepare the necessary things for baby’s needs such as: - Clothes, bonnet, booties, things that can
warm the baby in order to prevent hypothermia

Drink and eat food before labor - For energy source and prevent dehydration during labor.

Proper Hygiene - Very vital for the recovery state of the mother and to prevent further infections to
the baby

Continue eating healthy foods - Nutrition is very vital to help replenish all the energy that was lost
during labor and to supplement the milk production for the baby.

Proper Breastfeeding - Breastfeeding can help the baby to protect from allergies, sickness, obesity
and cancer.

Get your baby immunize - To prevent other health complications and boost immune system.

PALATTE 3: ADMINISTRATION OF MEDICINES

1. Oxytocin is a hormone that causes contractions of the uterus. It can be used to start labor or to speed up
labor that began on its own. Contractions usually start in about 30 minutes after oxytocin is given.
Side Effect
 a fast, slow, or uneven heart rate;
 excessive bleeding long after childbirth;
 severe headache, blurred vision, pounding in your neck or ears; or.
 confusion, severe weakness, feeling unsteady.
 Nausea
 Vomiting

2. Plain LR 500 s used to replace water and electrolyte loss in patients with low blood volume or low
blood pressure. It is also used as an alkalinizing agent, which increases the pH level of the body.

Lying on left side can relive pressure on the coccyx and to have the least amount of weight in the vena cava

Side Effects
 back pain.
 chest pain, discomfort, or tightness.
 decreased heart rate.
 difficulty breathing.

3. Enoxaparin is an anticoagulant that helps prevent the formation of blood clots

Dosage

 1.25 ml or 40 mg subcutaneous every 24hrs

Side Effects

 Mild irritation
 Pain
 Bruising
 Redness, and swelling at the injection
 Fatigue or fever may also occur
 Localized allergic reactions in 2%,
 Increased bleeding in 2%,

Enoxaparin is usually injected in the stomach area. You must use a different area of the stomach each time
you give the shot. identify the injection site on the left or right side of the abdomen (approximately 3
inches from the belly button).

When should I stop taking enoxaparin during pregnancy? Women should be advised to stop the
enoxaparin when contractions begin. For a planned delivery, most guidelines recommend stopping
enoxaparin within 24 hours, and this is especially important if an epidural is desired.

4. Nalbuphine is used is used to relieve moderate to severe pain

Paracetamol, also known as acetaminophen, is a medication used to treat fever and mild to moderate
pain.
Dosage

 0.5 ML IV every 2 hrs. for Nalbuphine

  650mg Oral every 4 hours for Paracetamol

WHEN NEEDED ONLY

Side Effect

 Sedation (36%)
 Clamminess (9%)
 Nausea and vomiting (6%)
 Dizziness (5%)
 Xerostomia (4%)
 Headache (3%)

Paracetamol

 This drug usually has no side effects.

5. Aluminum and Magnesium Hydroxide is used to treat heartburn, acid indigestion, upset stomach,
bloating caused by gas, or stomach discomfort caused by eating or drinking too much.
Dosage

 30 ml Orally every 2 hours for indigestion

WHEN NEEDED ONLY

Side effects
Do not swallow them whole. To avoid the chalky taste, take with water or milk.
 diarrhea
 constipation
 loss of appetite
 unusual tiredness
 muscle weakness

6. Metoclopromide is used for stomach and esophageal problems. It used to trat and prevent nausea and
vomiting

 10mg IV q4hrs PRN

Side effects:
 feeling tired
 Diarrhea
 Feeling restless

7. Pitocin is a hormone used to induce labor or strenghten uterine contractions. It is also use to control
bleeding afterbirth.
 6 mUnits/m; decrease dose to 4 mUnits when contraction progressed to 5-6cm dilation
Side effects:
 Nausea
 Vomiting
 Stomach pain
 Irritation at injections site
GET FETAL HEART RATE  120 BPM NORMAL
110 and 160 beats per minute

TT- 2 doses given Feb. 15, 2021 1st dose

July 18, 2021 2nd dose

Ma’am based on your lab results, everything appears to be normal, and there's nothing to be concerned
about. We’re waiting for the lab results of Rapid Antigen Test and urinalysis.

PALATTE 4: ENDING THE SHIFT

Maam Remember what I said; I'll recommend you to the next Student Nurse on duty. Don't worry, maam;
we'll see each other at the same time tomorrow, and the doctor will be taking rounds shortly; if you have
any questions or require clarification, you may ask the doctor; and if you have any concerns before I go,
you can phone the next nurse on duty. Thank you for your time, ma'am; I'll go ahead. God's bless you.

ENDORSEMENT:
Good Day, I am student nurse Reinzor Bacaron under the labor & delivery ward. I would like to refer to
you my patient. Room 457, Pt. Lucero, Denise Grace 19y/o, unmarried, came in due to GI distress and
abdominal pain under the service of Dr. Valle.
(-) vomiting
(+) GI distress
(+) Abdominal Pain
VITAL SIGNS:
T- 36.3
BP- 120/80
RR- 20
PR- 81 SPO2-98%
TT- 2 doses given
Feb. 15, 2021 1st dose
July 18, 2021 2nd dose

Please admit under the service of Dr. Gloria

- VS q hourly
- Hook EFM monitoring; Monitor labor in progress
- Please monitor FHT
- I&O q shift
- DAT (direct antiglobulin test)
- IVF: D5LR 1L @ 120cc/hr.
Labs: INSTRUCTED FOR:
RAT (Rapid Antigen Test)
Urinalysis Sample specimen still not given
CBC DONE
AT ALL NORMAL VALUES
Chest X-ray DONE
• Impression: Normal Chest Findings
Blood Type O POSITIVE
Meds: - Start Oxytocin Drip –
Give PLR500cc fast drip while on left side lying position
Enoxaparin 40mg subcutaneous q24hrs
Nalbuphine 5mg IV q2hrs. PRN moderate pain or Acetaminophen 650mg PO q4hrs PRN
 Aluminum and magnesium hydroxide 30ml PO q2hrs PRN for digestion
Metoclopromide 10mg IV q4hrs PRN for nausea and vomiting
Pitocin 6 mUnits/m; decrease dose to 4 mUnits when contraction progressed to 5-6cm dilation
- Watch out for any unusualities
- Please Refer and facilitate lab works

QUESTIONS

- How many centimeters should the patient measure before pushing begins?
10 centimeters

- What do the terms “effacement:” and “station” refer to?

Effacement. Measured in percentage, effacement is a measurement of how thin and elongated the
cervix is. Station. Station is the measurement of the baby relative to the ischial spines

- When is oxytocin given and why? What are the priority nursing assessments during the administration of
oxytocin?
Oxytocin injection is used to begin or improve contractions during labor. Oxytocin also is used to
reduce bleeding after childbirth. Assess fetal presentation and station (fetal descent) prior to the
administration of oxy tocin. During oxytocin infusion titration, assess fetal heart rate (FHR), contraction pat
tern, and intensity every 15 minutes

- What are the priority nursing interventions following a vaginal delivery for the mother?
Assess postpartum patients, provide care and teaching, and if necessary, report any significant
findings. It is imperative for nurses to distinguish between normal and ab normal findings and to have a
clear understanding of the nursing care necessary to promote patients’ health and well-being

- What are the priority nursing interventions for the newborn following a vaginal delivery?
Common nursing interventions in the postpartum period focus on preventing excessive bleeding,
bladder distention, and infection; providing nonpharmacologic and pharma cologic relief of discomfort
associated with the episiotomy, lacerations, or breastfeed ing; and instituting measures to promote or
suppress lactation.

- When are APGAR scores obtained for the newborn and what areas are scored?
One of the first checks is the Apgar test. The Apgar test is a scoring system to evaluate the condition
of the newborn at 1 minute and 5 minutes after birth. The healthcare provider or midwife and nurses will
evaluate these signs and give a point value: Activity; muscle tone Pulse rate Grimace; reflex irritability
Appearance; skin color Respiration A score of 7 to 10 is considered normal. A score of 4 to 6 may mean
that the baby needs some rescue breathing measures (oxygen) and careful monitoring. A score of 3 or
below means that the baby needs rescue breathing and lifesaving techniques.

- How is a newborn assessment performed?

A brief, physical exam is done to check for obvious signs that the baby is healthy. Other procedures
will be done over the next few minutes and hours. These may be done in the delivery room, in the nursery
or in your room, depending on the hospital policy and the condition of the baby. Some of these procedures
include:

Measurement of the temperature, heart rate, and respiratory rate

Measurement of weight, length, and head circumference. These measurements help find out if a
baby's weight and measurements are normal for the number of weeks of pregnancy. Small or underweight
babies and very large babies may need special attention and care.

Cord care. The baby's umbilical cord stump will have a clamp. It needs to be kept clean and dry.

Bath. Once a baby's temperature has stabilized, the first bath can be given.

Eye care. Bacteria in the birth canal can infect a baby's eyes. Your baby will be given antibiotic or
antiseptic eye drops or ointment either right after delivery or later in the nursery to prevent eye infection.

Footprints. These are often taken and recorded in the medical record.

- What education do you anticipate for a first-time mother or parent?

Getting Help After the Birth Consider getting help during this time, which can be very hectic and
overwhelming. Many hospitals have feeding specialists or lactation consultants who can help you get
started nursing or bottle-feeding. Nurses also are a great resource to show you how to hold, burp, change,
and care for your baby.
How to handle a newborn, diapering and bathing your child, feeding and bupring, and sleeping
basics.