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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.