Patient Introduction
Location: Labor and Birthing Room
Time: 2220 hours
Situation: Brenda Patton is an 18-year-old patient, G1P0 at 38 2/7 weeks of gestation, admitted to the Labor and Delivery Unit at 2145 for rupture of membranes and uterine contractions. She was sent from OB-GYN office by the midwife, who confirmed rupture of membranes via sterile speculum exam with positive ferning, and the patient’s vaginal exam was 4 cm, 90%, -1 station. The patient reported SROM at around 9 a.m. this morning with clear fluid.
She has phoned her parent and her partner to inform them of her admission. Admission intrapartum orders have been initiated, initial labs have been drawn, and an IV catheter has been placed in her forearm.
Background: Brenda Patton’s pregnancy has been uncomplicated. She does not have any significant medical concerns and does not have any medication allergies. The patient wishes to have a natural birth without medication.
Assessment: Upon our initial assessment, the patient was 4 cm dilated, 90% effaced, and a -1 station, and the vaginal fluid was nitrazine positive. The provider has been notified, and prenatal records have been pulled. The lab report indicates that the patient’s group B strep vaginal-rectal culture taken at 36 weeks was positive.
Recommendation: Complete the admission process, review the lab results, and initiate treatment of group B strep.