This scenario is based on the Amelia Sung Complex Case in the National League for Nursing (NLN) Simulation in Nursing Education – Obstetric Scenarios scenario set.
This scenario is based on the Amelia Sung Complex Case in the National League for Nursing (NLN) Simulation in Nursing Education – Obstetric Scenarios scenario set.
Scenario Overview
Patient: Amelia Sung
Diagnosis: Labor Induction due to gestational diabetes
Brief Summary: This case presents a 36-year-old Filipino woman, G2P1 (L1) at 39 weeks gestation, who presented to the labor and delivery unit for labor induction due to gestational diabetes. Her diabetes has been well controlled during the pregnancy. The estimated fetal weight by ultrasound is 4000 g (8 lbs 13 oz), and at delivery an unexpected shoulder dystocia occurred. The student is expected to recognize the factors in the patient’s prenatal and intrapartum history that put her at risk for shoulder dystocia. The student should prepare the labor room with the necessary equipment in anticipation of an obstetric emergency. When the emergency is called, the student is expected to initiate appropriate actions, including assisting the patient into McRoberts position, and applying suprapubic pressure as dictated by the provider. In addition, the student should display effective communication with the obstetric team, the patient, and the support person.
Learning Objectives
General:
· Identifies the primary nursing diagnosis
· Identifies relevant patient history information
· Implements patient safety measures
· Identifies physical findings and diagnostics related to patient condition
· Implements provider orders appropriately
· Implements nursing interventions based on patient care needs
· Prioritizes nursing interventions
· Provides patient/family education and teaching
· Recognizes therapeutic and confidential communication techniques
· Reports findings directly and accurately to interprofessional team members
· Utilizes members of the health care team when appropriate
Scenario Specific:
· Recognizes significant risk factors in patient’s prenatal and intrapartum history that predispose her to shoulder dystocia
· Prepares the necessary equipment in labor room in anticipation of shoulder dystocia
· Performs appropriate nursing interventions when shoulder dystocia is identified
· Provides accurate documentation of critical delivery times
Patient Case Introduction to Students
Location: Labor and Birthing room
Time: 0700h
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. SUBECTIVE AMELIA WAS OBESSIVE TO GETTING TIRED, BECOS SHE HAS BEEN PUSH FOR LONG
During the past few contractions, the baby has started to crown. The provider has been called and has arrived, so Amelia may continue pushing.
Patient Details
Patient Data: Female – Age 36 years. Weight 83 kg (184 lbs). Height 157 cm (62 in).
Gravida: 2 Para 1 (L1)
Gestation week: 39
DOB: 7/11/XX
Allergies: Shellfish
Past Medical History: No surgical history.
Provider’s Orders
· Assessment:
o BP Q 1 hour x 2 then Q 4 hours
o Temp, HR, RR Q 1 hour
o Temp Q 2 hours after rupture of membranes intrapartum or if temp greater than 38° C (100.4° F) orally.
o Breath sounds Q 4 hours
o Head-to-toe assessment Q 4 hours
o Deep tendon reflexes Q 4 hours
o Vaginal exam
o Assess IV
o Continuous pulse ox
o Continuous external monitoring (fetal HR and uterine activity)
· Meds:
o Oxytocin 30 units in 500 mL normal saline IV. Begin at 1 mU/min (1 mL/hr). Increase 1 to 2 mU/min every 30 to 60 min until adequate labor achieved. Maximum 20 mU/min
o Lactated Ringer’s 1000 mL IV 125 mL/hr
o Epidural anesthesia via catheter infusion at 10 ml/hr
o Lactated Ringer’s 500 mL IV bolus (For nonreassuring fetal heart pattern)
· Respiratory:
o Oxygen 10 L/min per non-rebreather mask for nonreassuring (Category II or III) fetal heart rate
o May discontinue oxygen when fetal heart returns to reassuring (Category I)
· Routine Tests:
o Complete blood count, STAT
· Call orders:
o Temp > 38° C
o HR < 50, > 100
o RR < 12, > 24
o BP sys < 90, > 140; dia > 90
o SpO2 < 94%
o Meconium-stained fluid
o Nonreassuring fetal HR
o Rupture of membranes greater than 12 hours
Nursing Diagnoses
· Risk for Injury (to the fetus) related to trauma during the birth process
· Risk for Injury (to the mother) related to trauma associated with maneuvers employed during the shoulder dystocia or perineal trauma
· Anxiety related to the emergent situation and possible neonatal and maternal morbidity
Overview of Proposed Correct Treatment
· Wash hands
· Introduce self
· Identify patient
· Obtain fetal/maternal vital signs
· Check the diagnostics, provider’s orders and medication administration record (MAR) in the electronic health record (EHR)
· Assess IV site and fluids
· Assess the patient’s deep tendon reflexes
· Prepare the delivery table and bassinet in anticipation of delivery
· Prepare step stool in anticipation of an emergency delivery
· Change patient position
· Recognize that decelerations become severe and that variability becomes minimal when head delivers
· Stop the oxytocin infusion due to nonreassuring fetal heart rate
· Administer lactated Ringer’s solution bolus
· Give oxygen by non-rebreather mask
· Lower head of bed and assist patient into McRoberts position
· Call charge nurse and Neonatal Intensive Care Unit (NICU) to inform of emergency and need for additional assistance
· Apply correct suprapubic pressure, using step stool
· Communicate with provider when applying suprapubic pressure
· Encourage pushing
· Hand baby to charge nurse
· Provide education for patient and relatives whenever possible
Case Considerations
The identification of risk factors is the first step in the anticipation of shoulder dystocia. This patient’s history included excessive weight gain and prolonged second stage. Prompt action by the nurse must ensue upon the announcement of shoulder dystocia. Noting time of delivery of the fetal head is essential because it is estimated that a fetus can survive for approximately 6 minutes once the head is delivered before irreversible damage occurs. Requesting additional assistance using clear, direct language while assisting the patient into McRoberts position is expected. McRoberts maneuver, in which the mother’s legs are flexed back against her abdomen, allowing the pelvis to open to its maximum dimension, is the least invasive technique. The next maneuver would be adding application of suprapubic pressure with the palm or fist. Suprapubic pressure is applied at the direct request of the provider and is facilitated by the extra height of the step stool; the pressure may allow for the anterior shoulder to be pushed in a downward and lateral direction so that it passes under the pubic bone. If those two maneuvers fail, the provider should try other measures in a timely manner until the baby is delivered.
The nurse’s anticipation, prompt recognition, and immediate action are essential components for optimizing maternal and fetal outcomes in shoulder dystocia. Nurses must be able to act in a calm and organized manner once this emergency has been recognized. Several factors in this emergency support the need for protocols and simulation training: the need for a simple and direct request for additional help in the room; the importance of noting time of delivery of the fetal head;, the need to document maneuvers and their outcomes; and the value of clear communication among the obstetric team. Use of clear communication such as SBAR (situation-background-assessment-recommendation) is critical to ensuring patient safety. Practicing skills and communication for an event that is unpredictable is essential to improving outcomes in obstetric emergencies.
Nursing Process Care Plan Client Initials: Culture/Ethnicity: Support System: Unit: Room/Bed: Religion: Occupation: Age: Sex: Language: Current Work Status: Weight: Height: Marital Status: Highest Grade Completed: Primary Patient Complaint: Patient Medical History: Diagnostic Procedures (Not to include labs): Surgical Procedures: Pathophysiology/Etiology (Theory): Define patient primary problem and cause(s). Supporting Symptomatology: What patient data supports your selection of Pathophysiology? Developmental Stage (Theory): Utilize Erikson. Identify what stage is applicable to your patient based on their age. Developmental Stage (Actual): Identify what developmental stage your patient is ACTUALLY in. Describe behaviors/concerns that support your selection of this Developmental Stage. Vital Signs/Frequency: LAB RESULTS INTERPRETATION PATIENT’S LAB RESULTS NORMAL RANGE NURSING INTERVENTIONS AND ACTIONS DIAGNOSTIC RESULTS INTERPRETATION PATIENT’S DIAGNOSTIC RESULTS NORMAL RANGE NURSING INTERVENTIONS AND ACTIONS ASSESSMENT Subjective/ Objective NURSING DIAGNOSIS #1 (Physical) PLANNING/ OUTCOME (Client Centered) 1 Short Term 1 Long Term INTERVENTIONS (Nurse Centered) 1 Monitoring, 1 Action & 1 Teaching per Goal RATIONALE FOR INTERVENTIONS 1 per Intervention EVALUATION (Evaluate each Goal) ASSESSMENT Subjective/ Objective NURSING DIAGNOSIS #2 (Physical) PLANNING/ OUTCOME (Client Centered) 1 Short Term 1 Long Term INTERVENTIONS (Nurse Centered) 1 Monitoring, 1 Action & 1 Teaching per Goal RATIONALE FOR INTERVENTIONS 1 per Intervention EVALUATION (Evaluate each Goal) ASSESSMENT Subjective/ Objective NURSING DIAGNOSIS #3 (Psychosocial) PLANNING/ OUTCOME (Client Centered) 1 Short Term 1 Long Term INTERVENTIONS (Nurse Centered) 1 Monitoring, 1 Action & 1 Teaching per Goal RATIONALE FOR INTERVENTIONS 1 per Intervention EVALUATION (Evaluate each Goal) STUDENT NAME: Medication #1: Classification of Medication: Trade Name: Generic Name: Dosage: Dosage Forms: Routes: Why is THIS patient SPECIFICALLY receiving this medication? Side effects/Adverse reactions: Lab Values: CONTRAINDICATIONS: Nursing Implications/Responsibilities: STUDENT NAME: Medication #2: Classification of Medication: Trade Name: Generic Name: Dosage: Dosage Forms: Routes: Why is THIS patient SPECIFICALLY receiving this medication? (Include the action of medication) Side effects/Adverse reactions: Lab Values: CONTRAINDICATIONS: Nursing Implications/Responsibilities: STUDENT NAME: Medication #3: Classification of Medication: Trade Name: Generic Name: Dosage: Dosage Forms: Routes: Why is THIS patient SPECIFICALLY receiving this medication? Side effects/Adverse reactions: Lab Values: CONTRAINDICATIONS: Nursing Implications/Responsibilities: STUDENT NAME: Medication #4: Classification of Medication: Trade Name: Generic Name: Dosage: Dosage Forms: Routes: Why is THIS patient SPECIFICALLY receiving this medication? (Include the action of medication) Side effects/Adverse reactions: Lab Values: CONTRAINDICATIONS: Nursing Implications/Responsibilities: STUDENT NAME: Medication #5: Classification of Medication: Trade Name: Generic Name: Dosage: Dosage Forms: Routes: Why is THIS patient SPECIFICALLY receiving this medication? Side effects/Adverse reactions: Lab Values: CONTRAINDICATIONS: Nursing Implications/Responsibilities: Nursing Process Care Plan References Page