Nursing 331: OB/Labor & Delivery
Clinical
Labor & Delivery Case Study
February 2025
Case Study: Preparation for Labor and Delivery Clinical Experience
Patient Situation: Jody Moore, 28-year-old Native American, gravida I, para 0 at 38 weeks gestation,
telephones the triage unit for labor and delivery at 6 a.m. inquiring as to whether she should come in to be
evaluated. After scanning Jody's prenatal record and talking to Jody on the phone, the nurse questions her
about her contraction pattern. Jody states that she had irregular contractions throughout the night that kept her
awake. The contractions have not intensified. Jody's membranes are intact, and there was bloody show last
night. The nurse advises Jody to stay home and go about her usual activities.
1. Give examples of when Jody should go to the hospital for evaluation. (0.75 pts)
a. When her contractions get closer together (shorter amount of time between contractions).
b. When her contractions become more intense.
c. Jody’s water breaks (amniotic sac ruptures/ruptured membranes)
d. Fetus/baby stops moving.
e. A flow of blood is seen (almost resembles menstrual period bleeding)
2. Jody arrives at the hospital at 9:30 a.m. stating that her membranes just ruptured. List four important
assessments the nurse will need to document regarding the status of Jody’s membranes. (1 pt)
a. “What time did your water break?”
• This is an important question to ask because the longer the amniotic sac has been
ruptured, the higher risk of infection. Knowing when the water broke is a key driver in
the plan of care. The uterus is a somewhat sterile environment, meaning that it does not
have a microbiome. Once the amniotic sac is no longer intact, bacteria from the vaginal
canal can ascend, increasing the risk of infections such as chorioamnionitis or other
infections.
b. “Did you notice the amniotic fluid having any strong or foul odor?”
• Normal amniotic fluid should be odorless or if it does have an odor it should be mild. A
foul or strong odor may indicate an intrauterine infection, such as chorioamnionitis,
which can pose risks to both the mother and baby. If an infection is suspected, further
evaluation, such as maternal temperature monitoring, white blood cell count, and fetal
heart rate assessment, is necessary.
c. "What color was the amniotic fluid?"
• Normal amniotic fluid should be mostly clear or pale yellow. However, if the baby has
passed meconium (the first stool) in utero, the fluid may appear green or brown.
• The presence of meconium-stained amniotic fluid may indicate fetal distress and is
categorized based on its appearance as thin, moderate, or thick meconium. Thick
meconium is particularly concerning, as it increases the risk of meconium aspiration
syndrome, which can cause respiratory complications in the newborn. The newborn is
constantly swallowing amniotic fluid while floating in the womb, and if it has its first
bowel movement in utero it can aspirate this feces, causing it to go into the lungs.
• This is why if meconium is present, the healthcare team must closely monitor the baby
and prepare for possible interventions at birth, such as suctioning or respiratory
support if needed.
d. “What was the amount of the amniotic fluid/how much amniotic fluid did you notice
after your water broke?”
,Nursing 331: OB/Labor & Delivery
Clinical
Labor & Delivery Case Study
February 2025
• This is often described in terms of scant, moderate, or copious. These terms describe the
extent of the membrane rupture. A large volume of fluid, or large gush usually is
indicative of a complete rupture, whereas on the other hand a slow trickle may suggest a
high leak or partial rupture of the amniotic sac.
• This info if very important because low amniotic fluid levels, otherwise known as
oligohydramnios, could be a sign that was a rupture with insufficient fluid remaining,
which may compromise the well-being of the baby.
• On the other hand, excess amniotic fluid, or polyhydramnios, could be a sign of
underlying complications such as maternal gestational diabetes mellitus or even twin
pregnancy.
• If the leakage seems to be continuous, this could reflect prolonged rupture, which like we
mentioned earlier increases the risk of infection, and may require further medical
intervention.
3. Amniotic Fluid: (1 pt)
The pH of amniotic fluid can vary depending on many different things.
➢ Nitrazine pH Indicator Dye Test To Determine Ruptured Membranes: (Least Accurate!)
o Background:
▪ This test used to be performed all the time/very often in the past to a patient’s
amniotic membrane ruptured, which is a sign that labor is approaching. But, it is not
very accurate, and kind of outdated. Page 378 of the textbook (Lowdermilk et al.,
2023), talks about this test in further detail. There are other tests to check for
ruptured membranes which are more accurate than the Nitrazine pH test, like the
AmniSure ROM test and Actim PROM test. However, the nitrazine pH indicator
dye test it is still used in the hospital so still good to know.
o The Test:
▪ The test involves getting a cotton-tipped applicator (looks like a long Qtip) which
contains a nitrazine dye for determining the pH. Nitrazine dye changes color
depending on the pH of the solution it comes into contact with. It differentiates
amniotic fluid (which is slightly alkaline/basic aka higher pH).The long cotton swab
is dipped deep into the vagina in order to sample the fluids.
o Interpretation of Results: (Lowdermilk et al., 2023). If the nitrazine dye on the cotton-tip
applicator is...
▪ Yellow (pH 5.0), olive-yellow (pH 5.5), or olive-green (pH 6.0), this means that the
membranes are probably still intact since all of these pH values are acidic, and
identify vaginal and most body fluids.
▪ Blue-green (pH 6.5 ), blue-gray (pH 7.0), or especially deep blue (pH 7.5), the
membranes are probably ruptured, because these neutral to slightly basic/alkaline
pH values identify amniotic fluid.
▪ False tests results are possible because of the presence of bloody show or insufficient
amount of amniotic fluid. This is why the nitrazine test is not the most accurate
option for determining amniotic membrane rupture.
➢ Testing for Ferning or A Pretty Fern Pattern To Determine Ruptured Membranes: (Least
Accurate!)
o Background: More accurate than the Nitrazine pH test! :)
, Nursing 331: OB/Labor & Delivery
Clinical
Labor & Delivery Case Study
February 2025
o The Test:
▪ A drop of fluid from the patient’s vagina is spread across a clean glass slide wiht a
sterile cotton-tipped applicator. After the fluid dries on the glass slide, it is examined
under a microscope, where we are looking to observe for the appearance of
“ferning”, aka a frond-like crystalline pattern like the leaf of a fern. Amniotic fluid
exhibits this pattern.
▪ Don’t confuse with cervical mucus test, when high levels of estrogen also cause this
pretty “ferning" pattern.
▪ If there is no “ferning” seen under the microscope, then the specimen either was not
an adequate amount, or the specimen is not amniotic fluid bur rather urine, vaginal
discharge, or blood.
▪ Results are reported as either positive or negative, simple as that.
➢ AmniSure ROM & Actim PROM Immunoassay Tests = MUCH more accurate methods!
***I know we dont’ need to know all this speicifc info on these tests, but I found them interesting
and researched them, and thought why not add my notes here for future reference/studying
purposes ***
o AmniSure ROM test
▪ Background: The AmniSure ROM (Rupture of Membranes) test is a rapid, non-
invasive immunoassay that detects placental alpha microglobulin-1 (PAMG-1), a
protein found in high concentrations in amniotic fluid but in very low levels in
vaginal and cervical secretions. This test provides a reliable method to confirm
ruptured membranes and has been shown to be more sensitive and specific than
traditional methods like the nitrazine pH test and ferning test (Birkenmaier et al.,
2021).
▪ How It Works:
➢ 1. A sterile swab is inserted 2-3 inches into the vagina for about 1 minute to
collect a sample of vaginal fluid.
➢ 2. The swab is then placed in a test vial with solvent for 1 minute.
➢ 3. A test strip is inserted into the solution, and results appear within 5-10
minutes, similar to a home pregnancy test.
➢ 4. A positive result (two lines) indicates the presence of PAMG-1, confirming
rupture of membranes.
➢ 5. A negative result (one line) suggests intact membranes (Birkenmaier et al.,
2021).
▪ Advantages of AmniSure ROM:
➢ High accuracy (sensitivity: ~98%, specificity: ~100%) (Cousins et al.,
2022).
➢ Unaffected by vaginal infections, semen, urine, or blood, reducing false
positives.
➢ No need for a speculum exam, making it less invasive.
o Actim PROM test
▪ Background:
➢ The Actim PROM test is a rapid diagnostic tool designed to detect insulin-
like growth factor binding protein-1 (IGFBP-1), a protein prevalent in
Clinical
Labor & Delivery Case Study
February 2025
Case Study: Preparation for Labor and Delivery Clinical Experience
Patient Situation: Jody Moore, 28-year-old Native American, gravida I, para 0 at 38 weeks gestation,
telephones the triage unit for labor and delivery at 6 a.m. inquiring as to whether she should come in to be
evaluated. After scanning Jody's prenatal record and talking to Jody on the phone, the nurse questions her
about her contraction pattern. Jody states that she had irregular contractions throughout the night that kept her
awake. The contractions have not intensified. Jody's membranes are intact, and there was bloody show last
night. The nurse advises Jody to stay home and go about her usual activities.
1. Give examples of when Jody should go to the hospital for evaluation. (0.75 pts)
a. When her contractions get closer together (shorter amount of time between contractions).
b. When her contractions become more intense.
c. Jody’s water breaks (amniotic sac ruptures/ruptured membranes)
d. Fetus/baby stops moving.
e. A flow of blood is seen (almost resembles menstrual period bleeding)
2. Jody arrives at the hospital at 9:30 a.m. stating that her membranes just ruptured. List four important
assessments the nurse will need to document regarding the status of Jody’s membranes. (1 pt)
a. “What time did your water break?”
• This is an important question to ask because the longer the amniotic sac has been
ruptured, the higher risk of infection. Knowing when the water broke is a key driver in
the plan of care. The uterus is a somewhat sterile environment, meaning that it does not
have a microbiome. Once the amniotic sac is no longer intact, bacteria from the vaginal
canal can ascend, increasing the risk of infections such as chorioamnionitis or other
infections.
b. “Did you notice the amniotic fluid having any strong or foul odor?”
• Normal amniotic fluid should be odorless or if it does have an odor it should be mild. A
foul or strong odor may indicate an intrauterine infection, such as chorioamnionitis,
which can pose risks to both the mother and baby. If an infection is suspected, further
evaluation, such as maternal temperature monitoring, white blood cell count, and fetal
heart rate assessment, is necessary.
c. "What color was the amniotic fluid?"
• Normal amniotic fluid should be mostly clear or pale yellow. However, if the baby has
passed meconium (the first stool) in utero, the fluid may appear green or brown.
• The presence of meconium-stained amniotic fluid may indicate fetal distress and is
categorized based on its appearance as thin, moderate, or thick meconium. Thick
meconium is particularly concerning, as it increases the risk of meconium aspiration
syndrome, which can cause respiratory complications in the newborn. The newborn is
constantly swallowing amniotic fluid while floating in the womb, and if it has its first
bowel movement in utero it can aspirate this feces, causing it to go into the lungs.
• This is why if meconium is present, the healthcare team must closely monitor the baby
and prepare for possible interventions at birth, such as suctioning or respiratory
support if needed.
d. “What was the amount of the amniotic fluid/how much amniotic fluid did you notice
after your water broke?”
,Nursing 331: OB/Labor & Delivery
Clinical
Labor & Delivery Case Study
February 2025
• This is often described in terms of scant, moderate, or copious. These terms describe the
extent of the membrane rupture. A large volume of fluid, or large gush usually is
indicative of a complete rupture, whereas on the other hand a slow trickle may suggest a
high leak or partial rupture of the amniotic sac.
• This info if very important because low amniotic fluid levels, otherwise known as
oligohydramnios, could be a sign that was a rupture with insufficient fluid remaining,
which may compromise the well-being of the baby.
• On the other hand, excess amniotic fluid, or polyhydramnios, could be a sign of
underlying complications such as maternal gestational diabetes mellitus or even twin
pregnancy.
• If the leakage seems to be continuous, this could reflect prolonged rupture, which like we
mentioned earlier increases the risk of infection, and may require further medical
intervention.
3. Amniotic Fluid: (1 pt)
The pH of amniotic fluid can vary depending on many different things.
➢ Nitrazine pH Indicator Dye Test To Determine Ruptured Membranes: (Least Accurate!)
o Background:
▪ This test used to be performed all the time/very often in the past to a patient’s
amniotic membrane ruptured, which is a sign that labor is approaching. But, it is not
very accurate, and kind of outdated. Page 378 of the textbook (Lowdermilk et al.,
2023), talks about this test in further detail. There are other tests to check for
ruptured membranes which are more accurate than the Nitrazine pH test, like the
AmniSure ROM test and Actim PROM test. However, the nitrazine pH indicator
dye test it is still used in the hospital so still good to know.
o The Test:
▪ The test involves getting a cotton-tipped applicator (looks like a long Qtip) which
contains a nitrazine dye for determining the pH. Nitrazine dye changes color
depending on the pH of the solution it comes into contact with. It differentiates
amniotic fluid (which is slightly alkaline/basic aka higher pH).The long cotton swab
is dipped deep into the vagina in order to sample the fluids.
o Interpretation of Results: (Lowdermilk et al., 2023). If the nitrazine dye on the cotton-tip
applicator is...
▪ Yellow (pH 5.0), olive-yellow (pH 5.5), or olive-green (pH 6.0), this means that the
membranes are probably still intact since all of these pH values are acidic, and
identify vaginal and most body fluids.
▪ Blue-green (pH 6.5 ), blue-gray (pH 7.0), or especially deep blue (pH 7.5), the
membranes are probably ruptured, because these neutral to slightly basic/alkaline
pH values identify amniotic fluid.
▪ False tests results are possible because of the presence of bloody show or insufficient
amount of amniotic fluid. This is why the nitrazine test is not the most accurate
option for determining amniotic membrane rupture.
➢ Testing for Ferning or A Pretty Fern Pattern To Determine Ruptured Membranes: (Least
Accurate!)
o Background: More accurate than the Nitrazine pH test! :)
, Nursing 331: OB/Labor & Delivery
Clinical
Labor & Delivery Case Study
February 2025
o The Test:
▪ A drop of fluid from the patient’s vagina is spread across a clean glass slide wiht a
sterile cotton-tipped applicator. After the fluid dries on the glass slide, it is examined
under a microscope, where we are looking to observe for the appearance of
“ferning”, aka a frond-like crystalline pattern like the leaf of a fern. Amniotic fluid
exhibits this pattern.
▪ Don’t confuse with cervical mucus test, when high levels of estrogen also cause this
pretty “ferning" pattern.
▪ If there is no “ferning” seen under the microscope, then the specimen either was not
an adequate amount, or the specimen is not amniotic fluid bur rather urine, vaginal
discharge, or blood.
▪ Results are reported as either positive or negative, simple as that.
➢ AmniSure ROM & Actim PROM Immunoassay Tests = MUCH more accurate methods!
***I know we dont’ need to know all this speicifc info on these tests, but I found them interesting
and researched them, and thought why not add my notes here for future reference/studying
purposes ***
o AmniSure ROM test
▪ Background: The AmniSure ROM (Rupture of Membranes) test is a rapid, non-
invasive immunoassay that detects placental alpha microglobulin-1 (PAMG-1), a
protein found in high concentrations in amniotic fluid but in very low levels in
vaginal and cervical secretions. This test provides a reliable method to confirm
ruptured membranes and has been shown to be more sensitive and specific than
traditional methods like the nitrazine pH test and ferning test (Birkenmaier et al.,
2021).
▪ How It Works:
➢ 1. A sterile swab is inserted 2-3 inches into the vagina for about 1 minute to
collect a sample of vaginal fluid.
➢ 2. The swab is then placed in a test vial with solvent for 1 minute.
➢ 3. A test strip is inserted into the solution, and results appear within 5-10
minutes, similar to a home pregnancy test.
➢ 4. A positive result (two lines) indicates the presence of PAMG-1, confirming
rupture of membranes.
➢ 5. A negative result (one line) suggests intact membranes (Birkenmaier et al.,
2021).
▪ Advantages of AmniSure ROM:
➢ High accuracy (sensitivity: ~98%, specificity: ~100%) (Cousins et al.,
2022).
➢ Unaffected by vaginal infections, semen, urine, or blood, reducing false
positives.
➢ No need for a speculum exam, making it less invasive.
o Actim PROM test
▪ Background:
➢ The Actim PROM test is a rapid diagnostic tool designed to detect insulin-
like growth factor binding protein-1 (IGFBP-1), a protein prevalent in
