Unit 1 fetal development case study Elizabeth Kelley Buzbee AAS, RRT-NPS, RCP

Case study # 1 Your patient is in L & D. She is a 48 year old LAF. What else do you want to know about this patient?

Answer: Her vital signs: HR 125 sinus tachycardia, RR 18 bpm without retractions, BP 158/90 mmHg she is afebrile Her Sp02 : 99% on room air Her BS: clear to all lobe, diminished in the basal areas. Pregnancy history : week 28 Prior medical History: She is G4, P3 A1 Hx of Gestational diabetes with the last two pregnancies

What is the significance of her past history?

answer Her VS are ok, and she doesn’t seem to have an infection She has had 4 pregnancies, and 3 live births and one miscarriage. This puts her at risk for premature labor She is older, which makes her infant at risk The gestational diabetes puts the baby at risk If born today, the infant will be premature, but will be viable

What is the status of her fetus at 28 weeks? What are it’s chances of survive at this point?

answer At 28 weeks the fetus should have enough pulmonary capillary bed to exchange gas There should be enough alveoli for gas exchange The surfactant will be started but may not be at sufficient levels to prevent respiratory distress—the maternal diabetes will slow down surfactant production The CNS may not be developed enough to handle hypoxemia and hypercapnia appropriately

What is the blood flow from umbilical vein to umbilical artery?

Answer: Blood from the placenta gets to the single umbilical vein that goes to the belly and enters the liver where part of the blood goes to the portal circulation and the rest goes into the IVC via the D. Venosus where it enters the RA and goes into the Foreman Ovale & into the LA and LV to go out into the fetal body

What happens to the blood in the SVC?

answer The blood in the SVC drains the head and shoulders and this Desaturated blood enters the RA goes to the RV and into the pulmonary trunk where it is shunted away from the lung into the D. Arteriosus to the Aorta In the descending Aorta, this Desaturated blood mixes with the saturated blood from the IVC and drops the fetal P02 from the mid 30-40s to the mid 20s

Labor started with the water breaking [ruptured membranes] at midnight on Sunday. The labor was spontaneous, vertex, vaginal delivery. There were some early decells The baby is born at 0800 on Tuesday. He is a little boy. What if anything is significant about this series of events?

answer The time between the rupture of membranes and the birth of the baby exceeds 24 hours. This is called Premature rupture of membranes PROM which places the baby at risk for infection. SVVD is normal, but the delivery is premature early decells are not as serious as late decell. The HR rises back to baseline after each contraction

The umbilical cord is attached to what?

answer To the baby’s belly and to the placenta

How many blood vessels should be present in the umbilical cord?

answer Three vessels: Two umbilical arteries One umbilical vein

Which of these vessels carries blood with the most 02 [to the fetus]?

answer The umbilical vein carries blood to the fetus from the placenta

How do gases and waste product exchange between the mother and fetus?

answer The maternal blood flow goes to the maternal side of the placenta. The Pa02 is mmHg. The maternal blood is sent into the spaces around the chonrion villi where gases diffuse into the fetal blood. fetal capillaries in the placenta regroup into veins that drain into the single umbilical vein which carries the saturated blood to the fetus at a P02 of mmHg

At the OB gyn’s request, you draw and run a cord gas from the umbilical vein. You get the following data: pH 7.34 P02 40 PC02 35 What do you think about these gases?

answer This is wnl for cord gases for fetus between 25 weeks and term As soon as the infant starts to breath these data will change

The baby takes his first breath. If all goes well what happens?

answer The first few breaths will increase the RV so that [1] PA02 rises [2] lung Compliance rises The rising PA02 will reverse the longstanding pulmonary HTN and the RV pressure will drop which lowers RA pressure. The rising PA02 will raise the Pa02 and that will close the D. Arteriosus Once the cord is clamped the systemic blood pressure rises so that the RA pressure is lower than the LA pressure and the Foreman Ovale will close.

At 1 minute of life the baby has the following: Flaccid Extremities blue, central cyanosis HR 135 Regular at 55 bpm Grimaces with catheter to nose What is this infant’s APGAR score at 1 minute? What intervention is needed?

answer 0 for muscle tone 0 for color 2 for HR 2 for respiratory effort 1 for reflex APGAR at 1 minute is 5

What intervention is needed at this point?

answer 1.Warm and stimulate the baby by rubbing him down with towel. 2.Attach pulse oximeter to right hand [post-ductal] 3.Continue to monitor HR and RR 4.Assess the respirations for s/s of respiratory distress [Silverman score]

You are blowing 02 to his face. His Sp02 rises from 75% to 91% In 5 minutes, he has the following data: HR 140 Crying loudly [respiratory rate 48 bpm] Extremities blue but lips pink Arms and legs flexed What is his APGAR and what is his prognosis?

answer His APGAR at 5 “ is 7 and his prognosis is excellent, although he might need supplementary 02 for a day or so