Download The Care of a mother and her Newborn

THE CARE OF A
MOTHER AND HER
NEWBORN
By: Brittany Wisener & Katelyn Branney
INTRODUCTION & DEMOGRAPHICS









Patient: K.W., Caucasian and 19 years of age.
Unemployed with high school diploma.
Needs financial assistances, such as food stamps, cash
assistance, and WIC (Women, Infants, & Children Program).
No religious or cultural beliefs that would affect her care.
Engaged, but not present during delivery due to serving in the
National Guard.
Her fiancé's income is the primary support and he has
ownership of their current home.
Lives alone when he is not present, and does the cooking and
shopping.
Gravida 1, Para 1: Delivered, vaginally, to a baby boy on
November 7, 2010 at 1:37 a.m. He weighed 8lbs 13.2 oz.
Gestational age 40 weeks and 2 days. Cared for at 40 weeks and
3 days, the first post partum day.
ANTENATAL HISTORY
oPrimipara
oDid not have many healthy habits during her prenatal
care.
oPregnancy was due to an oral contraceptive failure.
oUnaware of her pregnancy because of her irregular
menses until April, 2010. She had her first prenatal visit
on April 15, 2010. During this time period she consumed
alcohol and periodically smoked. She also had poor
eating habits.
oPrenatal vitamins were not taken until August 25, 2010
oShe did not have any complications during this period;
however, during placentation she developed two
placentas.
oNo history of allergies, sexually transmitted infections,
GYN disorders, or surgeries.
oAll of the prenatal labs were within normal limits.
oMother is O+, baby is B+. This raises concern about
ABO incompatibility.
INTRAPARTAL









PERIOD:
CONTRACTIONS
Admitted for spontaneous labor
Onset of labor took place on November 6, 2010 at 2:00 p.m.
During labor she was given LR at 125mL/hr, pitocin was added to
the LR 7 min. after the delivery.
Contractions began to be monitored at 4:26 p.m.
Latent Phase: Contractions were approx. 4-6 min. apart & lasted
70-80 sec. long
Active Phase: Contractions 2-3 min. apart & approx 90 sec. long.
Transitional Phase: Contractions 1-2 min. apart & lasting approx.
60-80 sec. long.
Contractions became increasingly more intense & were
dangerously close together, which caused a non-reassuring fetal
heart rate.
Brethine 0.25mg, subQ was administered to relax the
contractions to keep the fetus safe.
INTRAPARTAL
PERIOD: CERVICAL EXAMS

First Stage of Labor: 11 hours & 21 min.

Second Stage of Labor: 16 min.

Third Stage of Labor: 7 min.

Total: 11 hours & 44 min.

Exam #1: 4:26 p.m. 3cm dilated, 70% effaced, -3 station. FHR approx. 120
bpm with moderate, variable accelerations.

Exam #2: 9:16 p.m. 4cm dilated, 80% effaced, -3 station. Amniotomy
performed at 9:17 p.m. Shortly after an epidural was administered. Two
attempts were made to insert the catheter, this caused CSF leakage.

Exam #3: 11:02 p.m. 7cm dilated, 100% effaced, -1 station. FHR 120 bpm
with moderate variable accelerations.

Exam #4: K.W. felt rectal pressure, 10 cm dilated, 100% effaced, & 0
station. FHR was120 bpm with moderate, variable accelerations.

At 1:37 a.m. on November 7, 2010 a male neonate was delivered vaginally
with no assisted devices, but K.W. acquired a second degree laceration.

Intrapartal labs were all what to be expected during a delivery.
MATERNAL












POSTPARTUM ASSESSMENT
Throughout the day vital signs were all within normal range.
Appetite was normal
Appearance morning: tired & skin was pale & warm.
Breasts were soft & non-tender
Uterus was at umbilicus, firm, & midline.
Bowel sounds were in all 4 quadrants, abdomen was round, soft & no
pain to touch.
Bladder was not distended
Lochia was rubra & a moderate amount. Perineal area was swollen &
well approximated.
Edema was +2 on her ankles & legs, but reported no signs of pain,
tingling, or numbness.
Hemorrhoids were not present.
Emotionally was concerned about her body image & was upset that
her fiancé was not present.
Bonding, she bonded well with her infant. She enjoyed holding, cuddling,
& talking to him.
MATERNAL
POSTPARTUM ASSESSMENT
Postpartum labs (Hgb & Hematocrit low)
 Chief Complaint: Pain, due to CSF leak upon
administration of the epidural.
 Headache, upper back pain, & shoulder pain.
 Administered Motrin, Vicodin, & IV Caffeine Sodium
Benzoate to control pain.
 Consent for Blood Patch was signed.

NEWBORN












POSTPARTUM ASSESSMENT
At delivery weighed 8lbs 13.2 oz (4004 g) & lost 5.1 % of his body weight.
Currently, weighing 8lbs 3.6 oz (3799.79g).
Throughout the day all vital signs were within normal range.
His anterior and posterior fontanels were soft, open, and normal to touch.
N.S.’s reflexes were all within normal limits (blinking, pupillary, babinski, palmar,
moro, sucking, & rooting).
No facial abnormalities, skin was pink and warm.
Lungs were clear upon auscultation and respirations were regular.
Abdomen was soft, round, and there were bowel sounds in all four quadrants.
There were few scratches on his abdomen from his sharp finger nails.
His umbilicus was intact, but drying appropriately.
All pulses were within normal limits and equal bilaterally.
Circumcised in the morning, checks were performed, and showed no
complications.
He was voiding adequately, but he has not yet passed his first stool.
Mother is breastfeeding, but newborn is having difficulties latching.
NURSING

DIAGNOSIS
Risk for impaired situational low self-esteem r/t pregnancy weight gain AEB expressing
concerns about excessive weight gain and impressing her fiancé.
-Use motivational interventions, such as motivating K.W., verbally, with positive
encouragement when she expresses concerns about body image and losing weight,
prn.
-Refer K.W. to a nutritional specialist to come up with a diet plan that will work
best with K.W.’s needs, stat.
-Educate and provide written information to K.W. on different exercises that she
can perform, stat.
-Encourage behavioral interventions, such as improving hygiene (showering, shaving,
brushing teeth, and getting dressed), prn.

Acute pain r/t a cerebral spinal fluid leak secondary to epidural administration AEB c/o severe,
constant headaches.
-Encourage K.W. to achieve adequate uninterrupted sleep in flat supine position,
prn.
-Administer ordered analgesics (Motrin & Vicodin), prn and assess pain level
before and after administration of medication.
-Encourage oral hydration of 6-8 (8oz) glasses of preferably water each day, prn.
-Institute comfort measures, such as applying a heating pad on the upper back and
shoulders, and providing an ice wash cloth over the eyes or forehead, prn.
NURSING DIAGNOSES CONT..


Knowledge deficit r/t being new to parenthood and its stresses AEB being a
young new mom with a lack of support.
-Encourage and stress the importance to K.W. that parent and child
interaction is vital for normal psychological development, prn.
-Educate K.W. that it is important for the infant to have the father
actively involved in N.S.’s life prn.
-Give K.W. written information that includes parenting tips and
resources for parenting support groups stat.
-Educate K.W. on the signs and symptoms of depression stat.
Risk for imbalanced nutrition r/t infants inability to correctly latch on and
transfer milk AEB having hesitancy when latching on and by needing nursing
staff to assist the baby to latch on affectively.
-Use self-attached breastfeeding, prn.
-Help K.W. establish different holding techniques that work best for
her newborn and herself when breastfeeding.
-Keep breastfeeding environment free from distraction and ideally a
dim, quiet, warm setting, prn.
-Instruct K.W. to look for pre-feeding behaviors, such as, searching,
rooting, and mouthing before attempting to feed, stat.
CONCLUSION






Concerns: How strong her & her fiancé's relationship is.
Lack of support
Leading to depression, stress, & sleepless nights, which
may affect the care of her new baby.
Self-esteem deteriorating, due to her body image never
meeting her expectations.
Lack of prenatal care, puts a high concern for not getting
the routinely care that an infant should receive after birth
(Doctor appointments & getting immunized).
The possibility of retained placenta fragments. By having
two placentas it will increase the likelihood of fragments
retaining in the uterus. This is a high concern because this
could lead to postpartum hemorrhage & this may become
life threatening.