OB Case Study Scenario 4

1. OB Case Study Scenario 4 Jaymie McAllister Isabella Bourke Jessica Nemerovsky

2. Patient Scenario • Tasha is a 28 year old G 6 P 4014 at 41 weeks gestation who has just arrived in L&D in active labor • Diagnoses: Active labor, rapid progression, 8/C/0 on arrival, membranes intact •  Height: 5’ 8” • Weight: 210 lb. • from prenatal visit 4 weeks ago

3. Patient Scenario • She has had only two prenatal visits beginning at 36 weeks gestation • She missed her last appointment, and her glucose screening. • She has a history of gestational diabetes. • Her last 2 infants were large for gestational age. • Both had shoulder dystocia at delivery • postpartum hemorrhage after each of those deliveries.

4. Patient Scenario • Lab: CBC, RPR, Type & screen drawn on admission with IV start and sent stat to lab • Labs from her prenatal visit 4 weeks ago showed Hgb 9.2 g/dl, Hct 25%  • Antepartum Testing: Sonogram at first prenatal visit to confirm dates – no fetal abnormalities noted.  • Medications: None – she has not taken prenatal vitamins or other medications. • She denies any drug or alcohol, denies smoking. • Diet: Regular – she has not followed any particular diet during pregnancy

5. Patient Scenario • Admission VS: • BP 138/88 • T – 99.1 degrees F • P – 96 R – 22 •  IV started in L forearm with #18 intercath, 1000 LR up and running • She is screaming that she has to push, has a large amount bloody show • She is planning a “natural birth” – does not want an epidural

6. Fetal Monitor Strip Early Decels, Fetal HR: 135, Contractions: 60- 70 seconds long, 90-150 seconds between

7. Question 1 • What assessment data about this patient is particularly pertinent?

8. Question 1 • Pertinent Information • Hx gestational diabetes, shoulder dystocia, macrosomia • Non-compliant with prenatal care (vitamins, glucose testing, etc) • Hgl/Hct levels • Gestational age • ROM, early decels

9. Question 2 • Is there additional data that you would like to obtain before you notify the physician about this patient?

10. Question 2 • Obtain a blood glucose, GBS status • Continuous FHM orders • Mom/fetus vitals • Question IV site for blood transfusions due to low hct/hbgr/t past postpartum hemorrhages • Fx of bleeding disorders, coagulations disorders, execessive bleeding w surgical procedures • Cultural considerationsjehovahs witness • Family support, living situation

11. Question 3 • How quickly do you need to contact the physician, and what information should be included in your report?.

12. Question 3 • Contact physician immediately • Birth is imminent • 8/C/0, presence of early decels, contractions 90-150 seconds apart lasting 60-70 seconds • Membranes still intact however, she says she wants to push • HX gestational diabetes, post partum hemorrhage, macrosomia • G6 P4 • Gestational age

13. Question 4 • What orders might you expect or request from the physician? How soon would you want the physician to see this patient? Continue the role play to demonstrate orders given and your request for how soon the physician should come to see the patient.

14. Question 4 • Physician to see pt STAT • High risk with a hx of gestional diabetes , macrosomia, hemorrhage, shoulder dystocia, no prenatal care, and post term gestional age • Request/anticipate blood loss and transfusion post birth • Orders to insert IV, 18G for blood • Ask about AROM

15. Patient Update • A few minutes later, her membranes rupture, with a moderate amount of green-tinged amniotic fluid. • She is screaming that she needs to push, and the baby’s head is visible at the perineum. • The doctor has just walked into the room. • He quickly delivers the baby’s head, but encounters a shoulder dystocia.

16. Patient Update • After several maneuvers, the baby is delivered and handed to the neonatal team, and the placenta is delivered. • The patient has a large amount of blood and clots pouring out of her vagina. • The blood pressure monitor shows the last BP 98/62 HR 132 taken 1 minute ago. • The doctor calls for the Postpartum Hemorrhage cart.

17. Question 5 • What interventions would be appropriate for this patient? Which of these interventions are highest priority?

18. Question 5 • Fundal massage • Hang pitocin, bring baby to the breast (if breast feeding)– stimulate bonding and release of oxytocin • IV fluids • 100% oxygen • NPO • Blood transfusion if necessary • CBC redraw • Perineal pain • Excessive pain is uncommon and can indicate a hematoma • Repair lacerations • Likely for large gestational age infants • Foley catheter • If this condition is not corrected, STAT hysterectomy be indicated

19. Question 6 • What potential problems or complications do you need to be prepared to handle? How would you do that? Are there other people that need to be involved to help?

20. Question 6 • Answered in above questions • Anticipate • Hemorrhage • Vaginal lacerations • Shoulder dystocia • Macrosomia • Uncontrolled BG in infant

21. Patient Update • After appropriate interventions, Tasha’s bleeding has slowed.

22. Question 7 • How often should the nurse reassess/reevaluate this patient’s status?

23. Question 7 • Assess Q15 minutes • Palpate fundas • Firm, boggy, midline, deviate or below umbilicus • Boggy uterus is indicative of uterine atony, not corrected results in PPH • Assess pads for locia • Amount of pad saturation, size of clots • 1 pad within 15 minutes or 2 saturated pads in an hour suggests PPH • Perineum Assessment/Pain • Assessment of laceration repair, additional tearing • Administer analgesics as needed • Reassess Vitals • 100.4F fever can be indicative of infection, decreasing uterine ability to contract and susceptible to PPH • Abnormal Vitals: tachycardia, cap refill greater than 3, decreased BP, increases RR • Redraw CBC and monitor I&Os • Assess signs of Hypovolemic shock • Color, skin temperature, pallor, cool, clammy skin • Anxiety, loss of consciousness • Assess patient anxiety levels and stress

24. Question 8 • Discuss appropriate teaching for this patient/family during and following their emergent situation.

25. Question 8 • Encourage voiding, straight cath • Cramping is expected • Ask nurses for assistance if needed • Ambulation the first few times out of bed • Ice packs for perianal area, SITS baths • Discharge teaching • Teach how to check own fundal and fundal massage • Contact PCP if • Uterus does not become firm with massage • Excessive bleeding and/or large clots • Fever greater than 100.4F • Persistent perineal pain or pressure • Expect dark stools if prescribed iron supplements • Constipation prevention • Fiber, laxatives

26. Question 9 • Discuss appropriate documentation for this patient in an emergent situation.

27. Question 9 • Document I&O • Bleeding • Estimated blood loss • Degree of hemorrhage • Instrument counts • Laceration assessment • Fundal assessment • Vitals • Response to medications