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L&D Clinical Rotation WorksheetJacksonville UniversitySchool of NursingStudent: Kaitlyn Emsley______________Date:8/28/2019Faculty:Professor MooreVaginal Delivery C-section Delivery(circle one)Client’s Initials__MS_ Age: _31_ G_7__T_3__P_0__A_4__L_3__ (on admission) EDD: _9/4/2019_Date of Delivery: _8/28/2019_Gestational Age at delivery: _39_____WeeksDate of Admission___8/28/2019__Allergies__NKA_____Significant Past OB/Medical/Surgical History:1 DNC after miscarriage 2010, 2 miscarriage with no DC 2012 & 2015. Vaginal delivery 2013, 2014 & 2016. Hypothyroid, pt. on Synthroid. Hx of asthma, oral herpes (Zovirx, daily medication), MTHFR. Psychosocial History:Pt. is a non-smoker. Pt. is married to her husband Jason, and they live at home with their 3 children. Maternal Risk factors present:Hx of MTHFR. Multiple pregnancy losses and D/C- produces scarring on uterus, increased risk of hemorrhage. Frequent of UTIs.
Maternal V/S on admission:B/P_113/57__ T_36.1__P_70__R_20__Maternal V/S after delivery: B/P_106/55___T_37___P_82___R_20__Admission Diagnosis: Breech for primary c-section.Significant Lab/Diagnostic Studies performed in Labor (CBC/H&H, PIH labs, glucose/Ultrasound)Prenatal:Blood: O+Hemoglobin: 11.4Platelets: 300Rubella: immuneRPP (syphilis): non-reactive HBsAg (Hep B): non-reactive HIV: non-reactive Chlamydia and gonorrhea: negative Pap smear: negative 1 hour glucose: 100Group B strep: negative Labs administered: Hemoglobin: 10.8 Hematocrit: 31.4 Platelets: 244 Labor & Delivery:Provide a narrative of your patient’s labor and delivery process along with rationale for each nursing action taken. Discuss the patient’s labor; why she was admitted, what interventions were done to her in labor (ROM, pitocin, antibiotics, etc), how her labor progressed (evaluation of contractions, cervical progress, station, fetal heart monitoring), the outcome (spontaneous vaginal delivery, C/S, forceps, vacuum) and any complications that arose during the labor or delivery. If CS or operative vaginal delivery performed, provide indication for procedure. C/S indicated because baby was in breech position in utero. 1200 time in OR. 1213 spinal was placed1234 C-section was started1244 Baby’s head was delivered1245 Placenta was delivered1246 Pitocin administered1250 Suturing of uterus began 1337 Time out of OR. After baby was born, bulb suction and tactile stimulation was performed.
EBL- 700Patient and baby tolerated C-section well with no complications. Pain Management in Labor(what was done for patient’s pain throughout labor including comfort measures, analgesics, regional or local anesthetics). Provide timeline including patient’s labor progress at time of relief offering:Epidural was given; bupivacaine w/ dextrose, duramorph, fentanyl. Patient tolerated procedure well. Good pain relief through out c-section. Nurse, Doctors, and husband provided support system in the delivery room. Baby birth weight, gender and Apgar score(include any infant resuscitation measures performed): Birth weight: 8 lb. 0oz.