Admission: (MFA) Active Labor

Arrived 3cm/70%/-2. She did not have a rupture of membranes but she does have UTI during pregnancy. Pt. is G1P0 at 39.6 wk and is 20 years old. There is no history of a birth plan.
1. Delivery: NSVD 2nd degree laceration. 620 mL blood loss. AGA newborn boy
  1. Blood loss >500 mL --> Risk for infection, risk for fluid volume deficit Mother was anemic going into labor so the blood loss would have a negative impact on her circulatory system (tachycardia, hypotension, fever, dehydration) Patient was given IV fluids to replace lost fluids, VS q4 hours.
  2. UTI in pregnancy --> Risk for infection, impaired urinary elimination, increased temperature. Mother's body is going through the infection process so her temperature would be elevated. Her UTI would cause problems in urinary elimination due to painful urination and urinary retention. It would be even more difficult to urinate and stay hydrated due to NPO status during labor for emergency c-section possibility. Patient was given water after labor and IV fluids. She was encourage to walk and use the restroom frequently.
2. LABS: Hematocrit 29.2; Hemoglobin 9.6; WBC 12.9; Platelets 294; RBC 3.72; Blood Glucose 105
3. Medications: Iron, antibiotics, Oxytocin
Newborn
1. Infant risk for meconium aspiration r/t meconium in amniotic fluid during AROM.
  1. Respiratory Distress, Hypoxia, Cold Stress, Polycythemia,
    1. Temp: 98.4, APGAR: 8/9
  2. Baby was immediately given a bath and suctioned.
2. Baby is breast fed
3. Vaccinations: Vitamin K, Hep. B, Erythromycin

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Admission: (MFA) Active Labor

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	Created by Grace Yoon over 6 years ago