sparanza
-/
PSYCHOSOCIAL
AGE
23
SETTING
LEGAL
Private prenatal office
ETHICAL
Mexican traditional health beliefs
Client needs vs practitioner's needs
ETHNICITY
Hispanic American
PRtORlTIZATION
Safety vs client desire for VBAC
Previous breech birth.
DELEGATION
PROBLEM
CO-EXlSTtNG
Breech presentation
PHARMACOLOGIC
COMMUNICATIONS
RhoGAM
DISABILITY
ALTERNATIVE THERAPY
Moxibustion; light; music
SOCIOECONOMIC STATUS
Multigravida; previous cesarean section
SPIRITUAL/RELIGIOUS
PRENATAL
Level of difficulty: Difficult
Overview:Requires knowledgeregardingbreech presentations and cesareansection. This case asks
students to
use
critical
thinking to
compare
and contrast VTBAG and
anesthesia used.
23
cesarean
section and the types of
-RRENATAL CASE STUDIES
Client Profile
Esparanza, isa_23~year'old'G2P1001'MHF at36wga-Shehada previousce-
^rcanisectlonwithan epidura!in Mexicosixyearsagof^ - breechpresentation"at
5,8,w:lks.ges^onalag^The babyweighed- pounds;She"is~five £eT^inucheds
Sln(VBAC)
^^LP W^: lolpounds.
this.
fcn
with
shewould like
Pregnancy' however she
saw
even consider doinga VBAC.
Case Study
ava^^^^^Z
six doctors before"shefounu d one'
Elpara,nzajeems anxiousat. today'sprenatalvisit-shet^ Acnursethatthe I
tt!^he.
ad±upwdeTher. ribsandshefearsa""the7cesa;e^ection'^
i. The followingdatais obtainedat thisvisit:
Wt 125 lb
FHT 140s URQ
Fundal height (FH) 35 cm
Fetal movement +(FM)
Urine chemstrip testing: all negadve
No HA, vision changes
NoCVAT
No edema
Questions
1.Whywasit so difficult for Esparanza to find an
obstetriGian whowould consider doing a VBAC?
Discuss the ethical dilemmas that exis^when the desiresandneedsofthe dientcome in conflictwith
those ofthe practitioner.
-\
2.What ar^ the routfne labs for this visit, and
are they done at this dme?
3.CompareandcootrastVBACandrepeatce-
sarean section for the followiiig: safetyfor both
C7
C7.
B.
mothef and bal^, cost, pdin; long-term effects, ef-
fccts onbreastfeeding, andparenting.
4.Her obstetrician asksforherpreviouscesarean
section records before he wUl even consider a
"s
VBAC.Why?
5.Whyarecesareansecdonsustiallydonefor
breech presentation?
6.Whenwoulda vagina]deliverybeconsidered
for a breechpresentation?
C7
c.
7.Howcanthebabybeencouraged tomove to a
cephalic presentation?
Rgure 1.2 Escms^le^ofbnech presentations.
CASE STUDY 8
8. What matemal/fetal conditions contribute to a
babypresentingin a breech presentation?
9. Compare and contrast spinal and epidural anesthesia for cesarean section.
10.If the babychangesto a cephalicpresentation
in the next two weeks but Esparanza does not go
into spontaneouslabor, can she besafelyinduced
11.What.methods can be used if any?
12. Esparanza begins to cry at the 39-week visit \
when she realizes that the baby has not yet changed
position. She;says that "Ijiist know it's going to be
terrible again.I'll never be able to breastfeedmy
babypostpartum; it's so painful." Howshouild the
nurse respond? '
foraVBAC?
References
Biancuzzo, M. (2003). Breastfeedingthe newborn: Clinical strategies for nurses (2nd ed. ).
St Louis, MO: Mosby.
Littleton, L., & Engebre.tson, J. C. (2002). Maternal, neonatal, and women's health nursing.
Clifton Park, NY: Thomson Delmar Learning.
Riordan, J., & Auerbach, K. (2005). Breast feeding and human lactation (3rd ed. ). Sudbury, MA:
Jones and Bartlett.
Simpson, K. R., & Creehan P. A. (2001). AWHONN perinatal nursing (2nd ed. ). Philadelphia:
Lippincott, Williams & Wilkins.
Ttran, D., & Mack, S. (2000). Complementary therapies for pregnancy and childbirth (2nd ed. ).
London: Bailliere Tindall.
relatedto safelyduringthisprocedure. Shewill be broughtinto the labor and
delivery area and given prostaglandin vaginally. In some cases they may give her
a prostaglandinpreparationorallythe nightprior to try to induceher. However,
the prostaglandin used orally (Cytotec) has been associated with uterine ruptare and maynot be a good choice with fetal demise. Prostaglandins maycause
hyperstimulation leading to placenta abruption and uterine rupture, and they
need careful monitoring. Depending on the type used, shewill have to waitfrom
30 minutes to up to six hours prior to oxytocin being used to induce the con-
tractions. Sometimes the prostaglandins themselves start contractions. She may
experience nausea, vomiting, and diarrhea with the prostaglandin use.
Anddiarrheal and antiemedc drugs maybe used. Her vital signswill need to be
monitored throughoutthe laboranddelivery.Vaginalexamsshouldbelimited
to reduce risk ofinfection. Painmedicadons maybe appropriate; however, they
should not be used to protect the stafffrom having to dealwith the mother's
grief. Theycan be used to help her dealwith the physicalpain of the induced
birth. Ifthey are used to cloud her cogitadve senses in the hope ofrelieving her
grief, they maydojust the opposite andmake it harder for her to cope with her
loss. Sheneedsemotionalsupport. Thismaybein theform ofa gentle touchor
simply remaining at her bedside for a longer dme when she is being checked.
Depending on her religious preferences, she might be asked ifshe desires some-
onefrom herfaithto be called,or the nursecanevensaya prayerwithher. She
maywear a saint's medal or amulet for spiritual protecdon. The nurse should be
careful when changing her gown not to lose these. These are ways of showing
the mother that she is being caredfor by persons who appreciate her griefand
respect her need to experience it. A doula who has experience working with
womendeliveringa deadbabywouldbe an excellentsupportfor her.
After the birth the mother and father should be given the opportunity to see
their baby. This can be difficult since the babyhasbeen deadfor some time. Wrap
the babyin a warm blanket andprepare the parents for thefactthat the babywill
notfeel like a livebaby.Encourage them to name the babyand, iftheywish,to explore the baby. The nurses should refer to the babyby name. The nurses who are
withherin deliveryshouldmakea pointofvisidngwithherpostpartum to allow
her an opportunity to ask questions and express her grief. Ended Beginnings by
Claudia Panuthos and Catherine Romeo provides some excellent insight into the
emotional journeys parents take after the loss of a baby. The stories told by the
mothers andfathers clearly demonstrate thatparents, although theyappearto be
in a state ofnon-feeling during this period, arevery much aware ofevery person
around them andthat thesepersons havea profound impacton howwell theparents can process the grieffor months andyearsafterward.
References
Panuthos,C., & Romeo, C. (1984). Endedbeginnings.South Hadley,MA: Bergin& Garvey
Publishers, Inc.
Varney, H., Kriebs, J., & Gegor, C. (2004). Varney's midwifer/ (4th ed. ). Boston: Jones and Bartlett.
Case Study 8:
Esparanza
1. Whywasit so difficultfor Esparanzato findanobstetricianwhowoiildconsider
doing a VBAC? Discuss the ethical dilemmas that exist when the desires and
needs of the client come in conflict with those of the pracdtioaer. Although
CASE STUDY 8
^ACcations
incarefully
selectedcasesissaferthanrepeatcesareansection,the ]
Ifa uterine mPturewere
have caused many"obste'tricilas
ram5I
to occur
^refuse toofferthkoption. Otherfactorsthatdiscourage obstetridanTfr^
-nngwomen this choice are that a VBAC delivery alsorequires that the ob.
stetncian, stay the hosPital durmS Ae active labor (whereasl
sections
finally) the comPensati°" for vagina7deliv"ery^s7ess3
^lb
ch!duled)'and'
ls
thanthatfor
at
cesarean
a
a cesarean
section-There
are
many
communTde'swhere^rs 1<
tlon. lsnolongeravailabletowomen-forcingthem tou"dergounnecessary su^-
geryor remain homefor unassistedvaginaldeliveries.
21
whatarethe
routme labs for tlus visit and
^g!°Mnand hfm atocrit/H&H)
whyare dley done
^ be checked.
at this time? Her
Hemodil'utio^ ^ye^st
?!tween. _24due
and32weel". °fgestationwhenthewoman"ex"pen:e"nce;T^wT;
hematocrit
asloweTma-ease ml C
mass.After 32weeks the red blood cell mass continues to increa7e"whileZ
plasma.
volumethe
increase occurs at a slower rate' with the result'bemg'asUgh't
risemH&H
end of the third trimester. The
hematocritis checLdTt636
to
Ae/aPid in"ease in
plasma
with
at
w^sto. assessmaterna!sfatus nearterm-Anano^"^ groupB strepto^occu;
^) cultureneedstobedone.Approximately35%ofallwomenhaAorGBS"
-thisseldomcausesa problem forthemother, ifthefetuswereto~become
mfected during the birth, the infection
could become
generalized, ie adine"^
infection and
death.
When
GBS
isoidendfied7t
h7mo?he^
cr^&al
n^onafal
be offered
prophylactic andbiotics during her labor to"protecrt h7'
ThLmothe', 'Lurine. is alsochecked for glucose, ketones, protein7n itrites"^d
even
^
,
leukocytes. HIVtestingandtestingforoAerSTIsmaybeIr^d^^.
3. Compare andcontrast VBAC andrepeat cesarean secdon for the foUowin^
safetyjwboth mother and baby'cost' Pam' long-term effec;7e7f^te7n
;, andparenting.
Compare and Contrast
VBAC
Less chance ofinfections; quicker recovery
-^
Safety for Mom
RepeatCesareanSecdon
Lesschanceofmpture ofutems; although
risk is low if client is screened well and
prostaglandins and oxytocins are not used
Baby is better able to clear excessive fluids
from the lungswitha vaginal delivery
Less
Postpartum much less
Feelingsofaccomplishmentand
SafetyforBaby
SaferonlyifVBACresultedinuterinerupture
Cost
More
Pain
Greaterpostpartum for extended period
Long-term Effects
empowerment
If desiredVBAC,mayfeel like a failure:risk
for adhesionsandlong-range pain and
complications from them
Ableto breastfeedimmediately
Effects on Breastfeeding
Often delayed; baby often gets supplements;
usually decreased success rate asdefined by
mother
Immediatebondingandabilityto hold
andcareforbaby;earlierdevelopment
ofconfidenceoncaringforbaby
Effects on Parenting
Delayed due to pain medications for major
surgery andinability to take charge ofbaby
for an extendedperiod
4. Her obstetrician asks for her previous cesarean secdon records before he will
even consider a VBAC. Why? He will want to review the operative records to be
certain that a low transverse uterine incision was made in the uterus and that
there were no complicadons with healing after the surgery.
5. Whyare cesareansecdonsusuaUydone for breechpresentadon?There is no
molding of the fetal head when there is a breech presentadon, thus there is a
greaterdangerofanaftercomingheadbeingunableto passthroughthepelvis.
This is true especiallysince the smaller bodyparts can begin to birth with less
than 10 cm dilatation (Figure 1.2 in core text). Other problems are increased
risk for prolapsed cord, uterine rupture, and fractures to the infant, usually to
the clavicle or humerus.
6. Whenwould a vaginal delivery be considered for a breech presentadon? A vaginal breech delivery may be consideredwhen the physician is experienced in
breech births and the mother is a muldpara with a history of uncomplicated
normal spontaneous vaginal deliveries (NSVDs); current low, but normal baby
estimated fetal weight (EFW) and the presentation is a complete breech presentation. A complete breech is the position where the fetal thighs and knees
are flexed.
7 Howcan the babybe eucouragedto move to a cephalicpresentadon?There
are several measures that may help. External version by the obstetrician in the
hospital may change the presentation. Sometimes a tocolytic medication is
used to relax the uterus while external manipulations are used to move the fetus into a more favorable presentation. This is usually done under ultrasound
andwith continuous fetal heart rate monitoring. If the fetus develops distress,
a cesarean section is immediately done. The manipulations may cause bleed-
ing; therefore, if the mother is Rh negative, RJhoGAM needs to be given.
However, after the versions these babies may reverse themselves back to
breech prior to delivery. Other methods that have been used to turn a breech
are having the mother try using a tilt boardseveral times a day, moxibustion
on the fifth toe, and the use ofmusicandlight to the lowerpelvic areato encourage the baby to move toward them. (Moxibustion is a traditional Chinese
medicine technique that involves the burning of mugwort, a small spongy
herb, to facilitate healing.)
8. What maternal/fetal condidons contribute to a baby presenting in a breech
presentation?
Uterine relaxation associated with high parity
Hydramnios
Oligohydramnios
Uterine abnormalities
Neoplasms
Contracted pelvis
Fetal anomalies
Placenta previa
CPD
9. Compare and contrastspinal andepiduralanesthesiafor cesareansection.
CASE STUDY
Compare and Contrast
Epidural
-^
Maybeusedinlaboriftryingfora VBAC,then
Timing
increased if cesarean section is needed
Mother mayfeel pulling sensations but not pain
Pain/Discomfort
None
Often reported
Spinal
Not used for labor
Usuallydoesnotfee]anything
Post Anesthesia Headache
Possible
Post Anesthesia Backache
Often reported
10. If the babychanges to a cephaUcpresentation m the next two weeks but
ranzadoesnotgomtospontaneouslabor,canshebesafelyinducedfor a
VBAC? Use ofprostaglandins and oxytocin for VBAC is the one factor that
greatly increases
risk for uterine
rupture. If used, great caution and
observation
areneeded.Theobstetricianshouldremainwithinthedeliveryunitatalltime's
in case an immediate cesarean section is needed.
11. Whatmethodscanbeusedifany?InductionwithanattemptedVBACincreases
theriskforruptureduterus. However,sincetheobstetricianmustremainwith
a^woman having a VBAC, he or she will often admit several women wishir
VBACwho areclose to their due dates andinduce them at the same time.
12. Esparanzabeginstocryatthe39-weekvisitwhensherealizesthatthe 1
n^tyetchangedposition. Shesays,"Ijustknowit'sgoingtobeterribleagau,
I'Uneverbe able to breastfeed my babypostpartum; it's sop^d. "~^o^
should thenurse respond? Mexican women tend tofearcesarean^ection'and
seen aslifethreatening to themother (Simpson, 2001).Thenurseneedstoal~
.
ESParanza to
ex press
her fears and also needs to listen
to what
problems
she_experienced, last. time sothatshecanaddresseachone. Use'op^ended
S!!mCTt!i_e.g" "Te"me aboutyourlastdeliver7-"Esparanzamayseekhelp
from a curanderos, a natural healer, to tryto reposition thebaby.
References
Biancuzzo, M^(2003). Breastfeeding thenewborn: Clinicalstrategies fornurses(2nded. ).
St Louis, MO: Mosby.
LittIe,t!n'_L;_&Engebretson-J-c-I2002)-Maternal,neonatal,andwomen'shealthnursing.
CliftonPark,NY:ThomsonDelmarLearning.
Riordan,J.,& Auerbach, K.(2005). Breastfeedingandhuman lactation (3rdcd. ).Sudbury, MA:
Jones and Bartlett.
' ---. " .."..
Simpson, K. R, & Creehan P.A. (2001). AWHONN perinatal nursing (2nd ed. ). Philadelohia:
Lippincott, Williams & Wilkins.
Tiran,D,& Mack,S.(2000). Complementar/ therapiesforpregnancyandchildbirth(2nded.:
London: Bailliere Tindall.
Case Study 9:
Sarah
1. BasedonSarah'sobstetricalhistory,listtwomajorconcernsforthispregnancy.
A history ofan LGAinfant, two SAB, repeated urinary tract infecrio^-and
yeastinfections, alongwith a babywho experienced RDS, hypoglycemia, and