NCMA 219 RLE Course Practicum Unit 4 Selwyn C. Suataron BSN 2Y21A Clinical Scenario You are working as a Labor and Delivery Nurse at a local hospital. Patient A.M., a 26 year old G3 P2 2002 at 41 weeks of gestation came in having contractions and feeling uncomfortable. Upon internal examination, the cervix was found to be 3 cm dilated. Fundic height was noted to be 40 cm. She was then admitted for monitoring of labor and delivery. She was initially advised to continue mobilizing. Obstetrical history was taken and documented. Her first baby was delivered 4 years ago via normal spontaneous delivery with birthweight of 3,700 grams. The second baby was delivered 2 years ago via forceps delivery with birthweight of 3,900 grams. In this pregnancy, she was diagnosed to have gestational diabetes mellitus at 28 weeks age of gestation. Pelvic ultrasounds were normal and antennal care was unremarkable. The baby was moving actively normal prior to labor. Four hours later, spontaneous rupture of membranes occurred. She was examined again and the cervix was still at 3 cm. An oxytocin infusion was started to augment labor with cardiotocograph monitoring. After 4 hours, the cervix was 7 cm. After 4 hours again, internal examination revealed 10 cm. She was then transferred to the delivery room. She was encouraged to start active pushing and 30 minutes later, the head had crowned in a occipito-anterior position. The midwife noticed that the head did not extend normally on the perineum and that the chin appeared to be fixed in the perineum. She had attempted delivery of the shoulders with the next three contractions but this had not been achieved. Concept Map Accomplish the concept map by filling in the needed data. Be ready to discuss it in class. NCMA 219 RLE Course Practicum Unit 4 1 Patient Name Patient A.M. Diagnosis Diagnosis: G2P2 2002 at 41 weeks of gestation diagnosed with Gestational Diabetes Mellitus at 23 weeks of gestation Pathophysiology Gestational Diabetes Mellitus GDM is a condition where non-diabetic women become diabetic halfway during their pregnancy. The main cause of GDM is yet unkown, whether the insulin's response to carbohydrates are inadequate, or there's an excessive resistance to insulin. GDM is causing difficulty in controlling blood glucose and insulin levels in balance within the system of not only the pregnant woman, but also to the baby growing inside her. It causes hyperglycemia, glycosuria, polyuria, hyperphagia, polydipdsia, and polyphagia. 💡 The early detection of this condition is significant and vital for proper management. She was diagnosed at 23 weeks of gestation which means it isn't too late to intervene and treat her condition. Medical/Surgical Rx Pelvic ultrasound was carried out and found out everything to be normal. Antenatal care was also performed right after the examination. Internal examination was also done several times to make sure that the cervix is fully dilated. 💡 Pelvic ultrasound and internal examination are the perfect examinations to be ruled out in this case. These examinations help assess the current condition of the mother and the baby. Diagnostic Tests The patient was diagnosed with Gestational Diabetes Mellitus during her 28th week of gestation. The doctors at that time would have probably made an order of Fasting Glucose Test or Oral Glucose Tolerance Test to confirm the diagnosis 💡 Diagnostic tests like this helped in identifying problems and risks that the mother would have faced blindly along the road. Without this diagnosis, the health care team would have taken a different course of treatment. That's why proper assessment and diagnosis is the key to a better planning and out ruling of interventions. Medications The mother received an infusion of Oxytocin after her water broke with her cervix only dilated at 3cm. 💡 Oxytocin was the right drug of choice in this case. Oxytocin promotes peristaltic movement of the cervix and helps in dilatation of the cervix. It also aids in the pain management of the mother since Oxytocin is our natural hormone responsible to make us feel less hurt, stressed and anxious NCMA 219 RLE Course Practicum Unit 4 2 Risk Factors Risk Factors Risk Factors Gestational Diabetes Cephalopelvic Dysproportion Induced Labor 💡 CPD The mother was diagnosed with Gestational Diabetes at her 28th week of 💡 Babies of mothers with gestational diabetes 💡 Right after the rupturing of the membrane, the mother received an infusion of gestation which is a risk factor in the occurrence of tend to be macrosomic (large in size that weighs oxytocin to induce her labor since her cervix is shoulder dystocia more than 4,000 grams). Because of limited space dilated for only 3cm which is also a risk factor for in the pelvic canal, large babies can sometimes not fit and have difficulty shoulder dystocia. Signs and Symptoms The weight of her previous baby in delivery. upon delivery was 3,900g and had to be delivered via forceps delivery. She had a history of delivering an almost-macrosomic baby. Signs and Symptoms Upon internal examination, the The midwife noticed that the chin dilatation of the mother's cervix was only 3cm following the spontaneous rupture of her membrane. NSG Dx and Intervention of the baby was fixed in the perineum of the mother. The head Nursing Diagnosis of the baby also didn't extend normally. NSG Dx and Intervention Risk for fetal injury Nursing Intervention Assist with preparation for delivery of fetus vaginally or surgically 💡 Helps ensure a positive outcome for the neonate. The incidence of stillbirths increases significantly with gestation more than 36 weeks. Macrosomia often causes dystocia. Signs and Symptoms NSG Dx and Intervention Nursing Diagnosis Risk for maternal injury Risk for fetal injury Nursing Interventions Perform McRobert's Maneuver 💡 Expected Outcome Patient will verbalize understanding of individual treatment regimen and the need for frequent selfmonitoring. Nursing Diagnosis Risk for decreased urine output Risk for water intoxication Nursing Interventions Closely monitor input and output 💡 to detect fluid retention Educate the mother regarding induced labor This maneuver will help in assisting childbirth with shoulder dystocia. 💡 mothers think of induced labor to be more painful than normal delivery. Apply suprapubic pressure 💡 The pressure applied will help decrease the fetal bisacromial diameter by adducting the anterior fetal shoulder. Teach the mother proper breathing exercises 💡 To keep the mother relaxed and focused. Observe the infant closely If none of the aforementioned interventions worked, perform NCMA 219 RLE Course Practicum Unit 4 3 Zavanelli Maneuver 💡 This is to push back the baby inside the mother's womb in anticipation of cesarean section. Prepare for cesarean delivery 💡 💡 Oxytocin-induced labor can predispose a newborn to hyperbilirubinemia and jaundice. Expected Outcome Patient is free of water intoxication and fluid retention Cesarean section is the best way to deliver a macrosomic baby to prevent fetal injury during labor. Expected Outcome Patient will participate in interventions to improve labor pattern and/or reduce identified risk factors. NCMA 219 RLE Course Practicum Unit 4 4
