Case Study: Pregnancy and Delivery

Complications

Lisette Allender MSN, RNC-OB

ObjectivesUpon completion the student will be able to: Identify the risk factors for developing

gestational diabetes Explain the oral glucose tolerance test Discuss education provided for preterm

labor Identify basic characteristics of a monitor

strip Discuss the causes of dysfunctional labor Analyze how and discuss why the patient

had this particular outcome

Directions Each group is expected to participate during

the case study. Each group has been provided with a set of

cards and a history sheet with important information about the patient.

As the case unfolds the groups will be presented with questions, answer to the best of your abilities. Several questions can have multiple answers, use the cards provided.

This case study relates to several important complications of pregnancy which you have read about.

“The primary objective of nursing care is to achieve optimal outcomes for both the pregnant woman and the

fetus” (Lowdermilk, Perry, Cashion, 2010, p. 581)

The Patient Sara is a 35 year old

Hispanic-American woman in her fifth pregnancy. She is presenting for prenatal care at approximately 24 weeks gestation.

Patient HistoryYou are the nurse assigned to assess the patient and take a history 5’2”, 230lb, unsure of pre-pregnancy

weight BP 140/90 HR 75 R 20 Temp 98.7 Uterine size appropriate for

gestational age

Previous OB History

G 5 T2 P 2 A 0 L 31. 39 weeks gestation – 7 lb 13 oz boy

born vaginally – natural2. 37 weeks gestation – 8 lb boy born

vaginally – IV medications only3. 32 weeks gestation FD (fetal demise)

vaginally – epidural4. 36 weeks gestation 8 lb 10 oz girl

born vaginally – epidural5. Current pregnancy

Patient History Complications:

Late to prenatal care Smokes occasionally, denies illegal drugs or alcohol Previous fetal loss at 32 weeks Previous preterm delivery Previous macrosomia

Family History: Mother of patient diagnosed with Type 2 Diabetes Father of patient has HTN and bladder cancer Husband was adopted, limited information on his family

Other information: Sara works as a preschool teacher She has been tired lately She exercises 0-1 times every week

Patient Prenatal Labs Hgb - 17 Hct - 40 Plt - 280 WBC - 8 HIV - neg Gonorrhea/

Chlamydia – neg Pap smear - neg

Hep B – neg Hep C – neg RPR – neg Blood type – A + 1 hour Glucola – 150mg/dl

Urine – neg for protein or bacteria GBS - positive

Nurse NotesPatient presents for follow up 3 hour OGTT test. Patient has been NPO for 8 hours and not smoked for over 12 hours.

The 3 hour Oral glucose tolerance test (OGTT) was completed due to Sara’s increased risk for GDM and 1 hour OGTT of 150mg/dL. Which of

the following values of her 3 hour OGTT did she fail, indicating a diagnosis of GDM?

A. Fasting – 110mg/dLB. 1 Hour – 170mg/dLC. 2 Hour – 165 mg/dLD. 3 Hour – 120 mg/dL

Sara is diagnosed with Gestational Diabetes. She is encouraged to change her diet, exercise, stop smoking, see a diabetes educator, and she is started on Glyburide.

As her nurse you educate her on the following:

Take her Glyburide at least 30 minutes prior to a meal

Carry a snack Check her blood sugar before each meal Eat small and more frequent meals Avoid high sugar foods Call if she develops symptoms Keep a log of her diet and blood sugars

If Sara had come to you for pre-conceptual counseling which of the following in the patients OB history

would you tell her puts her at a higher risk for gestational diabetes?

A. 36 week vaginal delivery 8lb 10oz B. 32 weeks Intrauterine fetal demiseC. Oligohydramnios with 2 previous

deliveriesD. 39 week vaginal delivery 7lb 13oz

Nurse Notes

Sara calls her OB’s office at 32 weeks gestation complaining of severe gas pains, lower back discomfort, and urinary frequency. You tell her to go to the hospital for assessment.

Sara is being assessed to determine whether she is experiencing preterm labor. What finding(s) would diagnose

preterm labor?

A. Fetal Fibronectin is present in vaginal secretions

B. Irregular, mild uterine contractions occurring every 12-15 minutes

C. The vaginal exam changes to 2cm/30%/-3 from 0/0%/-3

Nurse NotesSara arrives to Labor and

Delivery. You put her on the monitor and give her fluids. Her vaginal exam is 1/30%/-

3 at 32 weeks. Her membranes are intact.

Nursing Actions:• Hydrate the patient• Obtain a urine sample which is negative for bacteria• Lay Sara on her left side• Monitor her for several hours• Recheck her vaginal exam for change

After further monitoring, you note occasional contractions, and no change in her cervix.

You send Sara home with discharge instructions for

preterm labor.

Sara has demonstrated she understands your education about preterm labor symptoms when she

states which of the following?

A. “If I feel cramping I need to drink water, lay on my left side to see if it will go away”

B. “Only when I have painful contractions am I in preterm labor”

C. “I need to come to the hospital when my cervix dilates”

Sara arrives to the hospital at 38 weeks gestation for a scheduled induction of labor. She arrives at 0500 for her induction. She is placed on the monitors, IV started, labs drawn and Blood Sugar obtained of 95mg/dL.

Nurse Notes

MD Orders

• IV Normal Saline at 125ml/hr• Pitocin Protocol begun• Penicillin every 4 hours, due to GBS

positive status• External monitors• Blood sugars monitored every 8 hours

or if symptomatic• Epidural upon request

FYIOxytocin (Pitocin) is on the list of

high-alert medications designated by the Institute for

Safe Medication Practices because of the potential to

cause significant harm when used inappropriately

When managing the Pitocin for Sara’s induction, you should discontinue the

Pitocin immediately if :

A. Uterine contractions occurring every 3-5 minutes

B. A fetal heart rate of 180 with absence of variability

C. Sara needs to voidD. Rupture of amniotic membranes

Nurse Notes

At 1000:• The MD arrives and AROM Sara

and we find light meconium stained fluid. Vaginal exam 2cm/60-70%/-2

• Baby tolerated procedure well• Mother pain 3/10, denies wanting

pain medications at this time• Continue to monitor FHR, CTX• Continue to increase Pitocin per

protocol

Nurse Notes

At 1100:• Patient states her pain is

6/10 and desires pain medication.

• Vaginal exam reveals 3-4/70%/-2

• FHR reasurring, ctx every 4-5 minutes

• Sara given epidural for comfort

Nurses Notes

At 1400:• Sara exam is unchanged 3-4/70%/-2• Ctx every 8-10 minutes on external monitor• FHR is 150, moderate variability, no decelerations• Vital signs: BP 150/88, Resp 22, HR 80, Temp 99.1.

Based upon your nursing assessment of her progress, which one of the following

interventions would you do first?

A. Palpate the uterus during a contraction. When not contracting perform Leopold’s maneuvers to determine fetal position

B. Go take a quick lunch break while things are calm

C. Notify physician of current statusD. Do nothing but continue to monitor FHR

and reexamine in one hour

Nurse Notes• You palpate the uterus and

find the contractions are mild. The fetal position is determined with Leopolds and the baby is cephalic

• You notify the MD of no change in vaginal exam and request an IUPC.

• You place an IUPC and increase the Pitocin to get into a good pattern.

______________ is defined as long, difficult, or abnormal labor. It is caused by various conditions with the 5 factors affecting labor.

A. Augmentation of laborB. Vaginal birth after cesareanC. Postterm deliveryD. Dystocia of labor

Which of the following is listed as causing increased risk for labor

dystocia?

A. History of preterm laborB. Height of 5’2” and weight 230lbC. Hispanic-AmericanD. Diagnosis of Gestational Diabetes

With the information you about her labor progress, which of these TWO P’s is probably involved with causing Sara’s dysfunctional labor?

A. PassengerB. Pain C. PowerD. Passageway

Based on the patient history which of the following is the likely cause of

the labor dystocia?

A. Not enough Pitocin, need to increase

B. Needs more pain medication to relax

C. Macrosomia of newbornD. Dehydration of patient

You note the following fetal heart rate tracing. What does the tracing show?

A. Early decelerationsB. AccelerationsC. Late declerationsD. Variables

Nurse Notes

At 1545:• Turn the Pitocin off, IV bolus of fluid• O2 by face mask at 2 liters• Patient on left side• Vaginal exam 6/90%/-1• Notified MD of late decelerations will

continue to monitor FHR with no Pitocin• Patient has pain of 2/10, updated family

on plan

Despite efforts, the fetal heart rate shows a prolonged deceleration.

Due to the fetal heart rate drop and previous non-reassuring signs you call for an MD, notify NICU of compromised newborn and need for an operating room STAT. Sara is taken back for an emergency

c-section for fetal distress

Which of the following would you need to report to the NICU as they prepare to receive the baby in a STAT situation?

A. Non reassuring fetal heart rateB. Sara’s vital signs – BP 140/90, R 24, T

98.8, P 100C. Group Beta Strep positiveD. Light meconium stained fluid

Now let us watch the Emergency C-

section to save baby

How fast do you think they can get baby out?

http://www.medicalvideos.us/play.php?vid=3933

Desired Outcome

Meet baby boy Michael. Michael was born at 1615 by emergency c-section. He weighed 9lb

8oz and was 22” long. Apgars were 7 and 9. His initial blood sugar was 35. He required

monitoring for respiratory distress and blood sugars. Today he is breastfeeding and bottle

feeding and is doing well.

At Sara’s 6 week postpartum visit to her OB, which of the following

should be included in your patient education?

A. Need for follow up OGTTB. Increased risk for Type 2 DMC. GDM likely in future pregnanciesD. All should be included

References

Institute for Healthcare Improvement. (2012). Safe perinatal care: Reducing harm from oxytocin and measuring improvement. Retrieved from http://www.ihi.org/offerings/Training/SafeOxytocin/Pages/default.aspx

Lowdermilk, D. L., Perry, S. E., & Cashion, K. (2010). Maternity Nursing. (8th ed. ). Maryland Heights, MO: Mosby.