What is stillborn???
Stillborn is when your baby dies in the womb before delivery after twenty weeks of pregnancy. At times stillbirth can even happen before twenty weeks of pregnancy. Stillborn babies are confirmed by an ultrasound. The ultrasounds shows no heart beat or no fetal movement which confirms the diagnosis.
How to deliver the stillborn???
The stillborn baby must be delivered normally just like any other mother. The mother has to go through the whole labor and delivery process. Typically the mother is induced with Pitocin to stimulate contractions and vaginal medications to help prepare the cervix. A cesarean delivery is done if there are complications during the labor and delivery process. As sad this may be, yes its true the mother must delivery her very own dead baby. It is necessary for the mother to have emotional and physical support while she goes through this tragic moment in her life.
What causes stillborns???
• Birth defects: About 15-20% of stillborns have this problem. Most of them are associated with genetic disorders such as down syndrome, environmental or unknown cause.
• Placental problems: about 25% of stillborns have this problem. One of the most common placental problem is placental abruption. This is when the placenta almost completely peels away from the uterine wall before delivery. This causes heavy bleeding and lack of oxygen to the baby.
• Poor fetal growth: About 40% of stillborns have this problem. Fetuses that grow to slowly are at increased risk for this condition. Women that have high blood pressure, smoking habits, and also poor nutrition can or will lead to poor fetal growth. For this reason prenatal care is important not just for the fetus but the mother also.
• Infections: About 10-25% of stillborns have this problem. Infections that cause this harm are genital or urinary tract infections, along with viruses. This conditions may go undiagnosed until serious complications occur such as fetal death or preterm birth.
• Umbilical cord accidents: About 2-4 percent of stillborns have this problem. The problems with umbilical accidents include a knot in the cord or abnormal placement of the cord into the placenta. These problems can deprive the fetus from oxygen.
How to Cope???
The loss of your baby can be devastating and overwhelming. Dealingwith the situation may be one of the most difficult experience of your lifetime but it has to be done. Everyone copes and deals with such situations differently but here are some tips.
• Take care of yourself: You must eat well and get plenty of rest to maintain good physical health which will help you cope emotionally.
• Express your feeling: You should talk about tour baby, your feelings, your grief and even your fears. Don’t hold it inside because it will only make it harder on yourself.
• Find support networks: Support networks can be your family, friends, and even your community. You can find support groups with parents that may have experienced the same situation. This will allow you to share your stories and feelings with those that have been in the same spot as you have been.
• Give yourself time: Yes its true that you will never forget your baby but you will eventually heal. Healing is something that takes time and patients, its not something that happens over night. Just give yourself the time you need to be able to cope with the situation, do not deprive yourself.
References

• http://www.acog.org
• http://www.marchofdimes.com
• http://www.plannedparenthood.com
• http://www.idsociety.org

The client is a 39-year old woman who is gravida IV, para III, at 38 weeks gestation. She reported to the labor and delivery unit complaining of uterine contractions. In 1 week, she is scheduled for an elective cesarean delivery. She states that she has been having lower pelvic pressure and mild contractions every 5 to 10 minutes, lasting 30 to 50 seconds. She called her obstetrician who advised her to go to the labor unit to be checked.

The client has three children, the last one of which was delivered by cesarean after the client’s labor failed to progress. The section required a vertical abdominal and a vertical uterine incision, which required a ventral repair last year. When she was 8 weeks pregnant, she visited her present obstetrician who apprised her of the risks of her pregnancy.

The client’s diagnostic findings on admission are as follows: Hematology: Hgb 11.5 g/dL, Hct 43%.

Upon examining the client, the nurse notes an indentation across her abdomen, abdominal rigidity, absence of vaginal bleeding, and no cervical dilation. Strong uterine contractions are occurring every 5 to 10 minutes. The client’s blood pressure is 106/70, her heart rate is 100 beats per minute and regular, and her respiratory rate is 28 breaths per minute and regular. Fetal heart tones are 146 BPM and regular; fetal monitoring shows no evidence of fetal distress. The client’s husband is at her bedside.

As the nurse continues her assessment, the client suddenly complains of severe pain during a contraction. Within minutes the client’s skin is cold and clammy, her heart rate is up to 120 BPM, her respirations are rapid and shallow, and her blood pressure drops to 100/76. The indentation across the client’s abdomen is pronounced and contractions have ceased. The monitor indicates fetal distress. The nurse prepares the client for immediate cesarean delivery.

1. Q) What can be inferred from the client’s admission data and present physical status?
A)The patient is in pre term labor and is also experience fetal distress and needs an emergency c-section.
2. Q) Of what significance is the client’s increased heart rate; drop in blood pressure; and cold, clammy skin?
A) The mother is in severe pain which is due to uterine tear which makes the mother and child in danger. The baby is loosing oxygen which is putting it in distress.
3. Q) What are the possible consequences of uterine tear to the client and her fetus?
A) The most severe consequence would be the death of the mother and child due to hemorrhage and lack of oxygen. For the baby would be hypoxia, acidosis, depressed Apgar score, admission to NICU. For mother cystotomy, severe blood lose, transfusion, need for hysterectomy.
4. Q) What nursing actions should take precedence in this situation?
A) Awareness of symptoms of uterine tear especially when a patient had a previous c-section. Also if the patient is receiving oxytocin they are at higher risk of uterine rupture.
5. Q) What additional information, if obtained upon admission, may have indicated the seriousness of the client’s condition?
A) Mother was already warned about the severity of her condition if she continued the pregnancy.
6. Q) If you were the client, how could the nurse best support you emotionally as well as physically?
A) Emotionally to talk her through the procedure and letting her know your there for her. Physically prepare her for any procedure, giving medications, and making her as comfortable as possible.
7. Q) How can the nurse best support the client’s husband while the client is being prepared for emergency surgery?
A) Informing the husband of the procedure and the possible outcomes that can occur and reassure that the doctor will do everything possible.
8. Q) How does the care of this client compare to other groups of clients with similar problems?
A) The basis of the care should be similar but every person has different physical and emotional needs.
9. Q) What critical thinking skills did you use to answer the questions in this case?
A) Common sense, understanding the signs and symptoms of hemorrhage, assessing the patient, knowing the patient history, etc.

2. The risks involved with emergency cesarean delivery that are generally not present with scheduled cesarean delivery are the highest risk for severe hemorrhage.

3. Advantages and disadvantages of a low transverse abdominal incision compared to the classic midline incision is the low transverse incision is not likely to rupture during another birth causes less blood loss and is easier to repair, it may not be an option if the fetus is large or if there is a placenta previa in the area where the incision would be made. This type makes VBAC is vaginal birth after cesarean possible for subsequent births. With the classic midline incision it’s rarely used because it involves more blood loss and is the most likely of the 3 types to rupture during another pregnancy; however, it may not be the only choice if the fetus is in a transverse lie or if there is scarring or a placenta previa in the lower anterior uterus.

4. You will know if the client is having postoperative complications such as hemorrhage by noticing vital signs abnormally low BP and high pulse rate, diaphoresis, cyanosis, and possible vaginal bleeding.

5. You would prioritize nursing diagnoses for the client by risk for infection, anxiety, pain management and comfort. Of course you would prioritize in the ABC’s.

6. The discharge teaching for the client differs from that of a woman who delivered vaginally by taking care of the incision by preventing infection, and

• Watch your incision for signs of infection, such as increasing redness or drainage.
• Hold a pillow against the incision when you laugh or cough and when you get up from a lying or sitting position.
• Remember, it can take as long as 6 weeks for a C-section incision to heal
• Remember, the more active you are, the more likely you are to start bleeding.
• Get lots of rest. Take naps in the afternoon.
• Increase your activities gradually.
• Plan your activities so that you don’t have to go up or down stairs more than necessary.
• Do postsurgical deep breathing and coughing exercises. Ask your doctor for instructions.
• Don’t lift anything heavier than your baby until your doctor tells you it’s okay.
• Don’t drive until your doctor says it’s okay.
• Don’t have sexual intercourse until after you’ve had a follow-up appointment with your doctor and you’ve decided on a birth control method.
• Don’t take a tub bath or use douches or tampons for 4 weeks

7. The advantages of responding to the clients concerns about her delivery method in a therapeutic manner versus a reassuring manner is not giving them false reassurance, showing concern, paying attention to what they have to say and giving them empathy.

8. The attitude and cognitive critical thinking skills you would use to address this case is by having a positive attitude, show caring and knowledge to prove that she is in good hands and recognize possible complications related to cesarean delivery.

BY:
Vanessa, Christine, and Cory, SVN
10/22/08

Multiple Births

Joey, C.

Liz, G.

Carla, F.

The client is a 27-year-old mother of one who gave birth to twin girls approximately 10 hours age. The client and her partner were initially distraught when they learned that she was carrying more than one fetus because they had not planned to have more than two children. However, as time passed, they became accustomed to the idea and, by the end of the 7th month of pregnancy, were looking forward to their anticipated twins.
The client was in labor for 6 hours. Following vaginal birth of the first infant, a cesarean was performed to deliver the second infant due to premature placental detachment. The first infant weighed 5 lbs, 1 oz and an initial Apgar score of 9. The second infant weighed 4 lbs, 4 oz, with an initial Apgar score of 7. Both infants were placed in warmers and monitored until they were stable. Neither infant is exhibiting signs of respiratory distress even thought they are small for their gestational age of 38 weeks.
The client is now recovering. Her vital signs are stable, and her dressing is dry and intact. She is fatigued and sleepy but eager to hold and care for her infants.

1. Why are multiple gestations considered high risk?

Preterm labor and birth
Pregnancy-induced hypertension
Anemia
Birth defects
Miscarriage
Twin-to-twin transfusion syndrome
Abnormal amounts of amniotic fluid
Cesarean delivery
Postpartum hemorrhage

2. What were priority nursing diagnoses for the client during her pregnancy?

At risk for malnutrition related to multiple pregnancy manifested by inadequate intake of less than 300 to 500 calories per fetus.

At risk for injury related to delivery of multiples manifested by large placenta and over distended uterus.

Acute pain related to uterine contractions and decent of pelvis and multiple fetus manifested by labor contractions.

3. How does the client’s birth process compare with that of a woman delivering one fetus?
.
Gestational age is more likely to be lower (pre-term),

Vaginal delivery takes place in the O.R. because they are at greater risk for complications at birth and cesarean deliveries.

The infants are smaller and easier to push out.

It’s common for the first child to be born cephalic, and second breech.

4. How will the client’s nursing care differ now that she is in the immediate postpartum period?

Monitor fluid shift (hypovolemic shock).

Monitor for hemorrhage.

If given epidural monitor for adverse reactions (depressed respirations).

5. Why is it especially important to maintain the newborn’s temperature within a normal range since they were born prematurely?

They do not have all the superficial body fat compared to a full term newborn. They do not have the ability to shiver as of yet (shiver reflex), so there is a greater necessity to keep them warm. And the hypothalamus is immature.

6. How will having two versus one infant to care for affect the client’s recovery?

The client will have questions about breastfeeding or bottle feeding multiple infants. After the birthing process the client will be physically and mentally exhausted, and will need extra support to help care for multiple infants until fully recovered from cesarean. The nurse may need to provide support groups for mother’s caring for multiple infants to relieve some of the stress experienced by the caregiver.

7. If you were the client, what concerns might you have about caring for twins?

How to feed multiples?
Nutritional intake needed to support multiples and myself?
Will I have enough support to help take care of the infants and household tasks while in recovery?
How am I going to learn how to manage time with feedings, lack of sleep, and lack of personal time?

8. What attitude and cognitive critical thinking skills did you use to address this case?

We compared regular birth to a multiple births to be able to note the major differences needed to watch out for. We also tried to think of the birthing process and come up with conclusions before looking to other resources.
References:
http://www.healthsystem.virginia.edu

http://kidshealth.org/parent/pregnancy_newborn/pregnancy/multiple_births.html

Leifer, Gloria MA, RN. Introduction To Maternity& Pediatric Nursing. Elsevier. 2007

The client is a 16-year-old sophomore in high school. She is single and lives with her parents. The client is at 32 weeks of gestation with her first pregnancy. She had been experiencing lower back pain and slight abdominal cramping for 6 hours prior to coming to the hospital. Her vaginal examination reveals that she is 0-cm dilated and her cervix is thick and high. The fetal monitor shows mild contractions every 5 to 6 minutes and a fetal heart rate varying between 142 and 150 beats per minute (bpm). The client wants to have the baby now, stating, “I’m tired of this and want to get it over with. I’ve heard that lots of times premature babies do just fine.” The client’s parents and her 18-year-old boyfriend are at her bedside.

1)What can you deduce about the client’s physical and psychological status?
-She is having false labor due to Braxton Hicks contractions manifested by slight abdominal contraction. Psychologically, she is anxious resulting in increased perception of pain and passive of the baby’s health.

2)What additional data would further support your deductions?
-The client is at 32 weeks of gestation with her first pregnancy; therefore, her lack of experience in childbirth affects her expectations. Her vaginal examinations revealed that she is 0-cm dilated and her cervix was still thick and high.

3)How do the client’s maturational needs differ from those of a women in her late 20’s or early 30’s?
-At the age of 16, she is still growing and her reproductive systems are still in the early state of development causing increased dietary nutritional needs such as vitamins, minerals, proteins, water, and calories.

4)What is the significance of the client’s statement about premature babies?
-Her statement insinuates that she has a lack of knowledge of the consequences of premature babies.

5)If you taught the client about the dangers of premature delivery at this time, how effective would such information be?
-It depends how much the client cares for the health of her child. However,considering her anxiety level, she may ignore the educational information provided.
6)What biases, if any, do you hold about adolescent pregnancy? How may biases influence the care rendered to pregnant adolescence?
-I believe adolescents who are sexually active at that age are old enough to make their own decisions. They’re also capable of dealing with their mistakes.
Biases is a major influence in the care of pregnant adolescence because it may reflect how the client is being cared for by the nurse.

7)How is pregnant adolescent similar to the elderly primigravida?
-Both cases require extremely careful monitoring of the fetus and at risk for complicated pregnancies. The demand for nutritional needs such as zinc, fiber, fat, and iron are increased in pregnant adolescent and elderly primigravida. They are both viewed by society as the adolescent is too young to be pregnant and the elderly is too old to be pregnant.

8)What critical thinking skills did you use to answer the questions pertaining to this case?
-ADPIE and applying our knowledge and experiences.

Maternal-Newborn Nursing
Induction of labor

The client is a 24-year-old woman who is primigravida and an uneventful pregnancy at 42 weeks gestation and is being admitted to the labor unit from her physician’s office for induction of labor. She has good prenatal care. The client is well-prepared for the birth experience, and she is accompanied by her husband who is excited and supportive. Her two nonstress test (NTSs) have been reactive, and a contraction stress test (CTS) was negative. Upon examination, the nurse notes that the client’s embryonic membranes are intact and her cervix is soft, thick, and dilated to 1cm. Her Bishop score is 8
The client’s physician orders continuous fetal monitoring with a 15-minute baseline followed by an intravenous (IV) infusion of Pitocin. The nurse initiates the IV infusion of 10mL of Pitocin in 1000mL of lactated ringer’s solution through an infusion pump at 0.5mU per minute. Since uterine contractions occurred within 15 minutes, the nurse increased the infusion to 1mU per minute. Following a 2-hour period of induction the client’s contractions are occurring every 3 minutes and lasting between 60 and 70 seconds.

1.) What could happen if the physician decided not to induce labor?
The placenta may become less effective by not giving enough nutrients and the baby may begin to lose weight. If the amniotic sac ruptures, this can cause an infection to the baby.

2.) What condition must be met before the clients labor can be induced?
When the mother is two weeks beyond the baby’s expected due date and the labor have not started naturally the client may be induced. When the placenta may not be functioning anymore it is a cause to induce labor. Preeclampsia can endanger mother health and restrict the flow of blood to the baby or a chronic or acute illness such as diabetes, HTN, kidney disease.

3.) How do NSTs and CSTs differ?
-The non stress test monitors the baby heart beat while at rest and movement. Usually done when the mother is past due, some other reasons to have the NSTs is if the mother has diabetes treated with insulin, HTN, gestational HTN, baby is small and not growing, if you have too little or too much amniotic fluid.
- The contraction stress test checks to see if the fetus will stay healthy during reduced oxygen levels that occur during contraction. This will test uterine contractions, fetal breathing, fetal muscle tones and movement. The amniotic fluid volume is also measured. The CST is done when the non stress test may not be in normal range.

4.) What is the significance of the client’s Bishop score?
The Bishop measures whether the mother have a favorable score of successful vaginal delivery. The clients Bishop Score is at 8, indicating a favorable score for the delivery.

5.) Why is it essential to administer Pitocin by infusion pump rather than by gravity?
An accurate control of the rate of infusion is essential and is accomplished by an infusion pump. Gravity may not give an accurate rate as a pump.

6.) Why was the client’s Pitocin insulin started at 0.5 mU/min and advanced at 15 min. intervals?
Starting at 0.5 mU/min because it is the initial dose, then gradually increases it at 30 -60 min intervals in intermittent orf1-2 mU/min until decided contraction pattern.

7.) How will the nurse know when to stop increasing the Pitocin dosage?
When the desire frequency contractions have been reached, the dose is gradually decreased as labor progressed to 5-6 cm of dilation.

8.) Which condition would necessitate discontinuing a Pitocin infusion?
In the event of uterine hyperactivity and or fetal distress.

9.) How should you prioritize nursing diagnoses for the client and her fetus during labor induction?
Assess fetal heart rate by intermittent auscultation by using a fetoscope or Doppler. Continuous electronic fetal monitoring to collect more data for inspection of the amniotic fluid.
Assess vital signs of mother every 4 hours.
Asses contractions by palpation, progress of labor, record urine output, asses mothers coping and relaxation technique, provide emotional support.

10.) What impact may nursing action concerning the clients’ labor induction have on
the outcome of her birth process?
Successful induced labor can be influenced by nursing actions like identifying
and responding to uterine hyper stimulation, fetal distress and assessing in a
timely manner leading to the prevention of possible complications of both mother and child.

11.) How does induction differ from augmentation of labor?
Induction of labor- is the stimulation of the uterus to begin labor
Augmentation of labor- stimulation of the uterus during labor to increase frequency, duration and strength and contraction.

12.) What attitude and cognitive critical thinking skills did you use to address this case?
Prioritizing patient’s needs management of labor process, providing support and information to the patient of occurring event to minimize anxiety.

1. What information suggest a potential problem and, therefore, requires further assessment? Patient sustained a second-degree laceration after an episiotomy was performed which increases her risk for infection. Also, patient states “Oh I do wish it had been a boy,” which could indicate postpartum depression or detachment from her newborn, which could affect the newborn psychologically.
2. What factors influence the position of the fundus following delivery? A full bladder interferes with uterine contraction because it pushes the fundus up and causes it to deviate to one side(usually the right side.)
3. What are the highest priorities when planning the client’s care? Assessing the patient’s vital signs(reporting any temperature >100.4F or abnormal heart or respiratory rates), fundus(evaluate firmness, height and location), lochia(observe for character, color, amount, odor and presence of clots), perineum(observe for hematoma, edema, and episiotomy using REEDA scale, note hemorrhoids and degree of discomfort, in any), bladder(observe for fullness, output, burning and pain), breasts(check for engorgement, nipple tenderness and breast feeding), bowels(determine passage of flatus, bowel sounds and defacation), pain(determine location, character, severity, use of relief measures and need for analgesics), extremities(observe for signs of thrombophlebitis, ability to ambulate and Homan’s sign), emotional(evaluate family interaction, support and any signs of depression state), attachment(observe for interest in newborn, eye contact, touch contact and ability to respond to infant’s cries) and cultural variations(observe for cultural practices that the staff can incorporate into a plan of care)
4. How should the client’s assessment change within the next 24 hours? Assess the fundus to make sure that it begins to descend about 1 cm(one fingers width) each day and also report if fundus does not stay firm. Continue to measure amount, color and odor of lochia, observe for hemorrhage and patient should be able to care for self and ambulate. Observe for edema, bruising and hematoma, assess hemorrhoids for extent of edema(can interfere with bowel elimination) and examine episiotomy or laceration for REEDA.
5. Compare the nutritional needs of the client with those of the nonlactating mother. For the lactating mother, she needs a well-balanced diet with high fiber(ex: whole grain breads, fruits and vegetables with skins,) and should not try to lose weight while nursing. For the nonlactating mother, she should delay a strict reducing diet until released by her healthcare provider to do so. Both mothers should continue taking any prescribed prenatal vitamins until after the 6-week checkup.
6. How will you know if your client is bonding with her baby? The mother will make eye contact with her baby, touch and talk to her baby, play and smile with her baby. Mothers who are bonding with their babies sing to them and tend to them when crying.
7. What critical thinking components did you use to address this case? We are both mothers so we took from our own experiences. We also compared normal and abnormal early postpartum vaginal births.

Primigravida Labor

The client is a 28 year old woman who is a gravida I, para 0, at 40 weeks gestation. This morning she noticed mild contractions, which steadily increased in strength and duration. When the contractions were occurring every 7 to 10 minutes and becoming uncomfortable, the client asked her partner to return home. She then consulted with her nurse practitioner who suggested she remain at the home until her contractions were about 5 to 6 minutes apart. Six hours later, the client reported to her birthing facility.
Upon assessment, the nurse notes that the client’s contractions are 4 to 5 minutes apart, moderately strong, and approximately 50 seconds long. Vaginal examination reveals cervical dilation of 3 cm, 75% effacement, and -3 station. Her embryonic membranes are intact. The client and her partner are excited, although the client appears tired and groan with the contractions. She states, “I’ll be glad when this is over, I don’t think I can stand much more.”

~~~~
1. Why did the nurse practitioner suggest that the client wait a while longer before reporting to the birthing facility?
- Because the contractions were 7 to 10 mins.
- Many first time moms experience Braxton Hicks contractions
- Having client report to the facility at a 5 to 6 minute contractions may help ensure true labor.

2. What can you infer about the client’s assessment and findings?
- That this is true labor because contractions are 4 to 5 minutes apart and 50 seconds long with a cervical dilation of 3 cm and 75% effacement.

3. What other data should you obtain about the client and her fetus?
- perform vaginal examination, measure the cervix, assess vital signs, continue monitoring contractions and fetal heart tones.
- assess for pain.

4. What conditions will you monitor for during the client’s labor to ensure they are within specified parameters?
-client’s BP will be measured, measure the cervix, and continue to monitor the contractions and its duration

5. How will you know when the client needs pain intervention?
- assess for any allergy to meds
- start pain assessment as soon as client arrives and continue pain assessment.

6. In what ways can a support person influence the labor experienced by a woman?
- Praising the woman and words of encouragement would help a woman deliver faster and more pleasantly.
- Advise family and spouse to give words of encouragement and encourage them as well.

7. Compare the client’s reaction to labor with that of multipara experiencing labor.
- The primigravida would not be able to discern between true and false labor like the multipara can. The primigravida may not expect the possible odd appearance of the newborn. Multipara might be ready to expect the shape and the appearance of the newborn.

8. What critical thinking skills did you use to address the question in this case?
- We took data from scenario, broke down findings and assessment to determine between false and true labor.