By: Kayla Cormier and Caitlin Darby OB CASE STUDY 5

Background Information Emily is a 27 year old G3 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.

Emily’s Scenario Diagnosis: Pregnancy at 35 weeks gestation History: Previous pregnancies were full term with no complications; No significant medical history Data: Height- 5’5” Weight- 161lbs Labs: Prenatal Labs all WNL Antepartum Testing: Sonogram at 18 weeks normal, indicated probable female fetus Medications: Prenatal vitamin once daily Diet: Regular Admission VS: BP: 154/90 T: 98.4 P: 88 RR: 22 Other: Husband on way from work 2 sons ages 3 & 5 with grandparents Patient tearful, worried about “losing my little girl”

Pertinent Assessment Data Subjective Assessment Emily has not felt her baby move today Objective Assessment Abdomen soft No contractions No fetal movement palpated Maternal pulse and heart rate heard on fetal monitor are synchronous No abnormal findings on physical assessment

Fetal Monitor Strip Moderate Variability Baseline: 88 (Normal Range ) Maternal Heart Rate: 88 (Normal Range )

Additional Data Needed When was the last time you felt your fetus move? Have you been counting fetal movements at the same time each day? If so what is a normal daily count? Is there any change from yesterday? Have you tried any interventions like eating, drinking or rest to try and stimulate fetal movement? Have you experienced any of these symptoms: Fluid leaking, vaginal bleeding, abdominal pain, fever/chills, dizziness, blurred vision, persistent vomiting, edema, muscular irritability, decreased urinary frequency, or painful urination? Reassess maternal vital signs Reassess fetal heart rate using electronic fetal monitor Reposition mother on left side to improve circulation “Flip, Float, Flow” Reposition on left side Start IV fluid bolus (NS or LR) Administer high flow O2 (100% via non-re- breather mask) Promote rest by providing a calm and quiet environment Questions for the Patient:Nursing Actions:

Next Step: Report to Physician When to contact the physician? STAT We want the physician to evaluate this patient immediately because If fetal death confirmed patient could die from DIC Information to include in the report: SBAR Situation A 27 year old female arrived at triage stating she had not felt her baby move today. She is suspected to be at 35 weeks gestation and is G3 P2002. Background All prenatal labs within normal limits Patient’s sonogram at 18 weeks was normal and indicated probable female fetus Patient is on a regular diet and takes prenatal vitamins once a day No complications with previous pregnancies Patient tearful; worried that she is going to lose her baby girl Assessment Data Height: 5’5” and Weight: 161lbs Vitals BP: 154/90 T: 98.4 P: 88 RR: 22 Abdomen soft No contractions or fetal movement palpated Maternal pulse and heart rate heard on fetal monitor are synchronous No abnormal findings on physical assessment EFM reads moderate variability Recommendations We have given the patient an IV fluid bolus, 100% oxygen, and repositioned her on her left side We have implemented all interventions to stimulate fetal well being with no improvement in fetal activity We recommend ordering an ultrasound to examine fetal cardiac function and well being We suspect fetal death due to an absence of fetal heart beat on the EFM and no fetal movement

Physician Orders and Interventions A verbal order for a STAT ultrasound Contact if patient’s status changes Updates on the results of the ultrasound Continuous maternal and fetal monitoring, interpreting and documenting results STAT ultrasound Highest priority Assess and document the patient’s vital signs and condition Q15min OrdersInterventions Physician states: “I am on my way to see the patient. I should be there in 10 minutes.”

Results of Ultrasound The results of the ultrasound have confirmed fetal death Revealed that the fetuses heart had stopped beating The patient and her husband have been informed and shown the results of the ultrasound by the physician and have been given instructions regarding delivery The parents were shown the ultrasound results to try and better understand the situation and develop coping strategies Nurses Role: Give the parents time to make a decision about their delivery options Stay with the family during birth and answer questions as needed Respect their wishes in regards to seeing the infant Allow the family the amount of time desired with their infant

Potential Problems Disseminated Intravascular Coagulation Prepare for delivery of stillborn fetus to prevent DIC Infection from retained products Fragile emotional state due to loss of fetus (grief) Contact chaplain/pastoral care for emotional support Encourage patient’s husband to stay with her for support Provide information on grief support groups and counseling Allow for the parents to be alone with their child after delivery Fetal Still birth Discuss delivery options with parents (immediate induction, waiting until labor begins, D&E) Follow hospital protocol for post-mortem care,documentation, policies and procedures Discuss options such as autopsy, lab work, and evaluation of placenta, membranes, and umbilical cord after delivery to try and determine cause of fetal death Physician or mid-wife Anesthesiologist Patient and husband Chaplain/Pastoral Support/Clergy Nurse Medical Examiner If provider and family desire an autopsy Funeral Home Director MaternalPerson’s Involved

Patient Teaching Identify the patient’s support system and coping mechanisms Grief support information given to the patient and her husband Offer to call the patient’s own clergy or pastoral care Inform patient of her options: To see and hold the infant after birth (discuss demise appearance prior to mother holding the infant) To bathe and dress the infant Time alone with the infant- helps the parents cope Choice of a room change after delivery or unit transfer if requested by the patient Discuss creating memories Footprints, photographs, blanket, and clothes

Patient Documentation Maternal vital signs and status Q15min Patient positioning EFM readings Nursing interventions Physicians verbal orders Support persons contacted Medications given (if any) Emotional status Once delivered: Fetal demise time Age Maternal factors Anomalies

References Cacciatore, J. (2013). Psychological effects of stillbirth. Seminars in Fetal and Neonatal Medicine, 18(2). Retrieved from S X Downe, S., Kingdone, R., Norwell, H., McLaughlin, M., & Heazell, A. (2012). Post- mortem examination after stillbirth: Views of uk-based practitioners. European Journal of Obstetrics & Gynecology and Reproductive Biology, 162(1). Retrieved from S X Stacey, T., Thompson, J. D., Mitchell, E. A., Ekeroma, A., Zuccollo, J., & McCowan, L. E. (2011). Maternal Perception of Fetal Activity and Late Stillbirth Risk: Findings from the Auckland Stillbirth Study. Birth: Issues In Perinatal Care, 38(4), Retrieved from term=Maternal+Perception+of+Fetal+Activity+and+%09Late+Stillbirth+Risk%3A +Findings+from+the+Auckland+Stillbirth+Studyhttp://www-ncbi-nlm-nih-gov.ezproxy.hsc.usf.edu/pubmed/ Yakoob, M., Lawn, J., Darmstadt, G., & Bhutta, Z. (2010). Stillbirths: Epidemiology, evidence, and priorities for action. Seminars in Perinatology, 34(6). Retrieved from S