Casey Stevens Julianne Tamoney OB Case Study # Five Casey Stevens Julianne Tamoney

Background Information Emily is a 27 year old G 3 P 2002 at 35 weeks gestation who has just arrived in L&D triage after calling her obstetrician because she has not felt her baby move today. Casey

Emily’s Scenario Diagnoses: History: Data: Lab: Antepartum Testing: Pregnancy at 35 weeks gestation History: Previous pregnancies full term with no complications. No significant medical history Data: Height: 5’5” Weight: 161 (25 lb. pregnancy weight gain) Lab: Prenatal labs all WNL Antepartum Testing: Sonogram at 18 weeks normal, indicated probable female fetus Medications: Prenatal vitamin once daily Diet: Regular Admission VS: Blood Pressure: 154/90 Temperature: 98.4 degrees F Heart Rate: 88 Respirations: 22 Other: Husband on his way from work, 2 sons ages 3 & 5 with grandparents Patient tearful, worried about “losing my little girl” Julie

Pertinent Assessment Data Subjective: Mother stated that she has not felt her baby move today. Objective: Abdomen soft, no contractions or fetal movement palpated No abnormal findings on physical assessment Maternal pulse and heart rate heard on fetal monitor are synchronous Casey

Electronic Fetal Monitor

Additional Information Needed Questions to ask Emily: When was the last time you felt your baby move? Have you been counting fetal movements at the same time everyday? If so, what was the normal daily count and the quality of movement. Have you tried any interventions like eating, drinking, and resting to promote fetal activity? Have you experienced any of these symptoms: Fluid leaking Vaginal bleeding Abdominal Pain Fever/Chills Dizziness Blurred Vision Persistent Vomiting Edema Muscular irritability or convulsions Decreased urinary frequency Painful urination Julie

Nursing Actions Reassess maternal vitals Reassess fetal heart rate by using an electronic fetal monitoring Stat call to the physician We want the physician to see this patient stat because the patient could die of DIC Casey

Next Step: Reporting to the physician Situation: A 27 year old female came into triage because she has not detected any fetal movement today. She is suspected to be 35 weeks gestation with a G3 P2002. Background: The patient has had no complications with previous pregnancies. The patient’s prenatal labs came back all within normal limits. The patient’s sonogram at 18 weeks was documented as normal. The patient is on a regular diet and taking prenatal vitamins once daily. Assessment: Admission vital signs: BP 154/90 T – 98.4 degrees F P – 88 R – 22 Abdomen soft, no contractions or fetal movement palpated No abnormal findings on physical assessment Maternal pulse and heart rate heard on fetal monitor are synchronous Recommendation: We would recommend repositioning the patient on her left side, administering an IV bolus, and administering 100 % oxygen. We would also recommend an ultrasound examination of the fetus. We suspect fetal death due to an absence of fetal movement and heart beat. Casey/Julie

Physician Orders and Interventions Continuous maternal and fetal monitoring. Assess and document the patients condition every 15 minutes. Verbal order for a stat ultrasonography. The highest priority in the situation would be to get the ultrasound results Contact if patient’s status changes Julie

Results The results from the ultrasound have confirmed fetal death. The family have been informed by the physician and have been given instructions regarding delivery. Nurse’s role: Stay with family during birth. Respect their wishes in regards to seeing the infant. Allow the family the amount of time desired with infants. Casey

Potential Problems Problems People Involved Still born Disseminated intravascular coagulation (DIC) To prevent this from occurring be prepared to have the physician induce labor or preform a cesarean delivery. Possible fragile emotional state due to loss of fetus. Be prepared to contact chaplain Infection from retained products. People Involved Patient’s physician or certified midwife Anesthesiologist Chaplain Nurse Medical examiner Julie

Patient Teaching Grief/Support information is given to mother/family. Offer to call patient’s own clergy or Pastoral care. Inform patient of her options: To see and hold the infant, discuss demise appearance prior to mother holding. To bathe and dress the infant. Give the parents time alone with the infant. Choice of room change after delivery or unit transfer if patient request. Discuss creating memories Footprints, photos, blanket, and clothes. Casey

Documentation Nurse’s interventions Verbal orders given by physician Maternal vital signs and status q15 EFM readings Time delivered If born dead or alive Presence of anomalies Gestation Julie

NCLEX Question A mother is pregnant again after a miscarriage. Which of the following nursing interventions will best assist in alleviating anxiety related to the prior loss? Referring the mother to a genetics counselor Providing the contact information for a perinatal loss support group Explaining all tests and procedures Performing an early ultrasound Casey

NCLEX Question A mother is pregnant again after a miscarriage. Which of the following nursing interventions will best assist in alleviating anxiety related to the prior loss? Referring the mother to a genetics counselor Providing the contact information for a perinatal loss support group Explaining all tests and procedures Performing an early ultrasound

NCLEX Question A client at 19 weeks gestation complains of vaginal spotting and cramping. Which of the following signs indicates an intrauterine fetal demise? (Select all that apply) No detected fetal cardiac activity Positive Spalding’s sign Increased estrogen levels Decreased estrogen levels Julie

NCLEX Question A client at 19 weeks gestation complains of vaginal spotting and cramping. Which of the following signs indicates an intrauterine fetal demise? (Select all that apply) No detected fetal cardiac activity Positive Spalding’s sign Increased estrogen levels Decreased estrogen levels

References Bhatia, v., Grivell, R., Wong, L. (2012). Regimens of fetal surveillance for impaired fetal growth. The Cochrane Library. Retrieved from http://onlinelibrary.wiley.com.ezproxy.hsc.usf.edu/doi/10.1002/14651858.CD007113.pub3/full Black, B. (2011). Interconception care for couples after perinatal loss: A comprehensive review of the literature. The Journal of Perinatal & Neonatal Nursing, 25(1), 44-51. Retrieved from http://ovidsp.tx.ovid.com.ezproxy.lib.usf.edu/sp-3.11.0a/ovidweb.cgi? T=JS&PAGE=fulltext&D=ovft&AN=00005237-201101000-00012&NEWS=N&CSC=Y&CHANNEL=PubMed Fordyce, L. (2013). Accounting for fetal death: Vital statistics and the medication of pregnancy in the United States. Social Science & Medicine, 92, 124-131. Retrieved from http://www.sciencedirect.com.ezproxy.hsc.usf.edu/science/article/pii/ S0277953613003080 Hofmeyr, G., Novikova, N. (2012). Management of reported decreased fetal movements for improving pregnancy outcomes. The Cochrane Library. Retrieved from http://onlinelibrary.wiley.com.ezproxy.lib.usf.edu/doi/10.1002/14651858.CD009148.pub2/ abstract;jsessionid=D1F7B8690E5EC6D648D1C3E85D0719C8.f02t04 Lexicomp. (2013). Neonatal loss after 20 weeks. Retrieved from http://online.lexi.com.ezproxy.hsc.usf.edu/lco/action/doc/retrieve/ docid/ disandproc/3558379#treatment