Upon completion the student will be able to: Identify the risk factors for developing gestationaldiabetes 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 thisparticular outcome
Each group is expected to participate duringthe case study. Each group has been provided with a set ofcards and a history sheet with importantinformation about the patient. As the case unfolds the groups will bepresented with questions, answer to the bestof your abilities. Several questions can havemultiple answers, use the cards provided. This case study relates to several importantcomplications of pregnancy which you haveread about.
“The primary objective of nursing careis to achieve optimal outcomes forboth the pregnant woman and thefetus” (Lowdermilk, Perry, Cashion,2010, p. 581)
Sara is a 35 year oldHispanic-Americanwoman in her fifthpregnancy. She ispresenting for prenatalcare at approximately 24weeks gestation.
You are the nurse assigned to assess thepatient and take a history 5’2”, 230lb, unsure of pre-pregnancyweight BP 140/90 HR 75 R 20 Temp 98.7 Uterine size appropriate for gestationalage
G 5 T2 P 2 A 0 L 31. 39 weeks gestation – 7 lb 13 oz boy bornvaginally – 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 bornvaginally – epidural5. Current pregnancy
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
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 forprotein or bacteria GBS - positive
Patient presents for follow up 3 hour OGTT test.Patient has been NPO for 8 hours and not smoked forover 12 hours.The 3 hour Oral glucose tolerance test (OGTT) wascompleted due to Sara’s increased risk for GDM and 1hour OGTT of 150mg/dL. Which of the followingvalues of her 3 hour OGTT did she fail, indicating adiagnosis 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 isencouraged to change her diet, exercise, stopsmoking, see a diabetes educator, and she isstarted on Glyburide.As her nurse you educate her on the following: Take her Glyburide at least 30 minutes prior to ameal 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-conceptualcounseling which of the following in thepatients OB history would you tell her putsher at a higher risk for gestational diabetes?A. 36 week vaginal delivery 8lb 10ozB. 32 weeks Intrauterine fetal demiseC. Oligohydramnios with 2 previousdeliveriesD. 39 week vaginal delivery 7lb 13oz
Sara calls her OB’s office at 32 weeks gestationcomplaining of severe gas pains, lower backdiscomfort, and urinary frequency. You tell herto go to the hospital for assessment.
Sara is being assessed to determine whethershe is experiencing preterm labor. Whatfinding(s) would diagnose preterm labor?A. Fetal Fibronectin is present in vaginalsecretionsB. Irregular, mild uterine contractionsoccurring every 12-15 minutesC. The vaginal exam changes to 2cm/30%/-3from 0/0%/-3
Sara arrives to Labor andDelivery. You put her on themonitor and give her fluids. Hervaginal exam is 1/30%/-3 at 32weeks. Her membranes areintact.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 noteoccasional contractions, and nochange in her cervix. You send Sarahome with discharge instructionsfor preterm labor.
Sara has demonstrated she understandsyour education about preterm laborsymptoms when she states which of thefollowing?A. “If I feel cramping I need to drink water, lay on my leftside to see if it will go away”B. “Only when I have painful contractions am I in pretermlabor”C. “I need to come to the hospital when my cervix dilates”
Sara arrives to the hospital at 38 weeksgestation for a scheduled induction of labor.She arrives at 0500 for her induction. She isplaced on the monitors, IV started, labs drawnand Blood Sugar obtained of 95mg/dL.Nurse Notes
• IV Normal Saline at 125ml/hr• Pitocin Protocol begun• Penicillin every 4 hours, due to GBS positivestatus• External monitors• Blood sugars monitored every 8 hours or ifsymptomatic• Epidural upon request
FYIOxytocin (Pitocin) is on the list of high-alert medications designated by theInstitute for Safe MedicationPractices because of the potential tocause significant harm when usedinappropriately
When managing the Pitocin for Sara’sinduction, you should discontinue thePitocin immediately if :A. Uterine contractions occurring every 3-5minutesB. A fetal heart rate of 180 with absence ofvariabilityC. Sara needs to voidD. Rupture of amniotic membranes
At 1000:• The MD arrives and AROM Saraand we find light meconium stainedfluid. Vaginal exam 2cm/60-70%/-2• Baby tolerated procedure well• Mother pain 3/10, denies wantingpain medications at this time• Continue to monitor FHR, CTX• Continue to increase Pitocin perprotocol
At 1100:• Patient states her pain is 6/10and desires pain medication.• Vaginal exam reveals3-4/70%/-2• FHR reasurring, ctx every 4-5minutes• Sara given epidural for comfort
At 1400:• Sara exam is unchanged3-4/70%/-2• Ctx every 8-10 minutes onexternal monitor• FHR is 150, moderatevariability, no decelerations• Vital signs: BP 150/88,Resp 22, HR 80, Temp 99.1.
Based upon your nursing assessment of herprogress, which one of the followinginterventions would you do first?A. Palpate the uterus during a contraction.When not contracting perform Leopold’smaneuvers to determine fetal positionB. Go take a quick lunch break while things arecalmC. Notify physician of current statusD. Do nothing but continue to monitor FHRand reexamine in one hour
• You palpate the uterus and findthe contractions are mild. Thefetal position is determined withLeopolds and the baby is cephalic• You notify the MD of no changein vaginal exam and request anIUPC.• You place an IUPC and increasethe Pitocin to get into a goodpattern.
______________ is defined as long,difficult, or abnormal labor. It is causedby various conditions with the 5 factorsaffecting labor.A. Augmentation of laborB. Vaginal birth after cesareanC. Postterm deliveryD. Dystocia of labor
Which of the following is listed as causingincreased 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 laborprogress, which of these TWO P’s is probablyinvolved with causing Sara’s dysfunctionallabor?A. PassengerB. PainC. PowerD. Passageway
Based on the patient history which of thefollowing is the likely cause of the labordystocia?A. Not enough Pitocin, need to increaseB. Needs more pain medication to relaxC. Macrosomia of newbornD. Dehydration of patient
You note the following fetal heart ratetracing. What does the tracing show?A. Early decelerationsB. AccelerationsC. Late declerationsD. Variables
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 willcontinue to monitor FHR with no Pitocin• Patient has pain of 2/10, updated family onplan
Despite efforts, the fetal heart rate shows aprolonged deceleration.
Due to the fetal heart rate drop and previous non-reassuring signs you call for an MD, notify NICU ofcompromised newborn and need for an operating roomSTAT. Sara is taken back for an emergency c-section forfetal distress
Which of the following would you need to report tothe NICU as they prepare to receive the baby ina STAT situation?A. Non reassuring fetal heart rateB. Sara’s vital signs – BP 140/90, R 24, T 98.8, P100C. Group Beta Strep positiveD. Light meconium stained fluid
Now let us watch theEmergency C-sectionto save babyHow fast do you think they can get baby out?http://www.medicalvideos.us/play.php?vid=3933
Meet baby boy Michael. Michael was born at 1615by emergency c-section. He weighed 9lb 8oz andwas 22” long. Apgars were 7 and 9. His initialblood sugar was 35. He required monitoring forrespiratory distress and blood sugars. Today heis breastfeeding and bottle feeding and is doingwell.
At Sara’s 6 week postpartum visit to her OB,which of the following should be includedin your patient education?A. Need for follow up OGTTB. Increased risk for Type 2 DMC. GDM likely in future pregnanciesD. All should be included
Institute for Healthcare Improvement. (2012).Safe perinatal care: Reducing harm fromoxytocin and measuring improvement.Retrieved from http://www.ihi.org/offerings/Training/SafeOxytocin/Pages/default.aspxLowdermilk, D. L., Perry, S. E., & Cashion, K.(2010). Maternity Nursing. (8th ed. ).Maryland Heights, MO: Mosby.