OB Case Study Scenario 4

Jaymie McAllisterIsabella Bourke

Jessica Nemerovsky

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

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.

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

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

Fetal Monitor Strip

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

Question 1

What assessment data about this patient is particularly pertinent?

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

Question 2

Is there additional data that you would like to obtain before you notify the physician about this patient?

Question 2

Obtain a blood glucose, GBS status Continuous FHM orders Mom/fetus vitals Question IV site for blood transfusions due to

low hct/hbg r/t past postpartum hemorrhages Fx of bleeding disorders, coagulations

disorders, execessive bleeding w surgical procedures

Cultural considerations jehovahs witness Family support, living situation

Question 3

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

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

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.

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

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.

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.

Question 5

What interventions would be appropriate for this patient? Which of these interventions are highest priority?

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

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?

Question 6

Answered in above questions Anticipate

› Hemorrhage› Vaginal lacerations› Shoulder dystocia› Macrosomia› Uncontrolled BG in infant

Patient Update

After appropriate interventions, Tasha’s bleeding has slowed.

Question 7

How often should the nurse reassess/reevaluate this patient’s status?

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

Question 8

Discuss appropriate teaching for this patient/family during and following their emergent situation.

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

Question 9

Discuss appropriate documentation for this patient in an emergent situation.

Question 9

Document I&O Bleeding

› Estimated blood loss› Degree of hemorrhage

Instrument counts Laceration assessment Fundal assessment Vitals Response to medications