OB Case study 5

1. OB Case study 5 By: Kayla Cormier and Caitlin Darby

2. 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.

3. 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”

4. 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

5. Fetal Monitor Strip Moderate Variability Baseline: 88 (Normal Range 110-160) Maternal Heart Rate: 88 (Normal Range 60-100)

6. Additional Data Needed Questions for the Patient: Nursing Actions: • 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

7. 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

8. Physician Orders and Interventions Orders 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 Physician states: “I am on my way to see the patient. I should be there in 10 minutes.”

9. 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

10. Potential Problems Maternal Person’s Involved • 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

11. 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

12. 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

13. References • Cacciatore, J. (2013). Psychological effects of stillbirth. Seminars in Fetal and Neonatal Medicine, 18(2). Retrieved from http:// www.sciencedirect.com.ezproxy.hsc.usf.edu/science/article/pii/ S1744165X12001023 • 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 http:// www.sciencedirect.com.ezproxy.hsc.usf.edu/science/article/pii/ S030121151200070X • 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), 311-316. Retrieved from http://www-ncbi-nlm-nih-gov.ezproxy.hsc.usf.edu/pubmed/? term=Maternal+Perception+of+Fetal+Activity+and+%09Late+Stillbirth+Risk%3A +Findings+from+the+Auckland+Stillbirth+Study • Yakoob, M., Lawn, J., Darmstadt, G., & Bhutta, Z. (2010). Stillbirths: Epidemiology, evidence, and priorities for action. Seminars in Perinatology, 34(6). Retrieved from http:// www.sciencedirect.com.ezproxy.hsc.usf.edu/science/article/pii/ S0146000510001102