PREPARED BY:DIANA KATHERINE MALINAOLR/DR

DEMOGRAPHIC DATA

CASE NO: 181***NAME: MS. PTL 40/FDx: PRETERM LABOR G2P1 Pregnancy Uterine 31 3/7 Weeks, Cephalic, PROM, Previous LSCS, GDM on diet, Vaginal Candidiasis

PHYSICAL ASSESSMENT

GENERALThe patient is 40 y/o,

FEMALE, weighs 65 kg. She is conscious, coherent

Vital Signs:BP= 120/70 mmHgPR=80 bpm RR= 20 /mtTemp=36.9⁰C O²Sat= 98%

Pallor of skin and nails

No palpable masses or lesions

SKIN

Maxillary, frontal, and ethmoid sinuses are not tender. No palpable masses and lesions

No areas of deformity

HEAD

Awake and alert

Oriented to Persons, Place, Time

LOC & ORIENTATION

Pale conjunctivae and no dryness

Pupils equally round and reactive to light

EYES

No unusual discharges noted

EARS

Pink nasal mucosa

No unusual nasal discharge

No tenderness in sinuses

NOSE

Dry mouth and lips

Free of swelling and lesions

MOUTH

No palpable lymph nodes

No masses and lesions seen

NECK AND THROAT

�ৣ Equal chest expansion

�ৣ No retraction

�ৣ Clear breath sounds

CHEST AND LUNGS

Regular rhythm

HEART

৩ Globular abdomen৩ Abdominal scars from previous LSCS৩ The patient complained of mild hypogastric pain

ABDOMEN

৩ Leopold’s Maneuver done: Cephalic presentation

৩ FHR: 152bpm

ABDOMEN

ে� Watery discharge since 1000H 13/08/12

ে� Thick, yellow patchy, cheese like particles adhere to vaginal walls

GENITALS

ে� Patient claimed pain and burning on urination

ে� Cervix: 1cm dilation, 50% Effacement, Station -3 Cephalic, Clear AF

GENITALS

৫ Pulse full and equal

৫ No lesions noted

EXTREMITIES

PATIENT HISTORY

PAST MEDICAL HISTORY On her 1st pregnancy cardiac

consultation was done all normal including 2D echo.

Prenatal Care: Previous Prenatal in Pakistan and a clinic in Riyadh.

PAST MEDICAL HISTORY Patient on Iron and

Prenatal Vitamins. No known allergies.

No history of Asthma, Hypertension, Renal disease and Thyroid problem.

PAST SURGICAL HISTORY

1993 Arterial Ligation (Heart) No report

PAST SURGICAL HISTORY 2008 Low Segment

Cesarean Section due to cord coil under General Anesthesia without complication

PRESENT MEDICAL HISTORY12/08/12. 1 day prior to admission

patient came to our OPD for prenatal check up. Patient claimed that 2 days ago

1. she has a reddish-brown in character and minimal vaginal discharge

2. mild hypogastric pain3. dysuria.

PRESENT MEDICAL HISTORYOb/Gyne History:

Gravida: 2Para: 1Gestational Age: 31 3/7 WeeksLMP: not sureLMP by early UTZ: 06-01-12EDD: 13-10-2012

PRESENT MEDICAL HISTORYOn Examination:

Vital signs: BP: 120/70mmHg, PR: 85 bpm, RR: 20 cpm, Temp. 37◦C, 02 Sat 96%, FHR: 138bpmIE: PV parous, closed. Cardiotocogram: shows reassuring no contraction.

Investigation: Amnisure ROM test: Negative

PRESENT MEDICAL HISTORY13/08/12 Patient came to ER with

chief complained of:1. watery discharged since 1000H

13/08/12 2. labor pains started since 2400H

12/08/12.

According to the patient she took Aspirin 81mg OD 4 days ago

PRESENT MEDICAL HISTORY

On Examination: IE: PV 1cm dilated, 50%effaced,

station -3, clear amniotic fluid.

No cardiac consultation on present pregnancy.

Sugar monitoring at home are not well controlled

INVESTIGATION

Amnisure ROM test: Positive

CTG or Cardiotocogram

CTG TRACING

NORMAL MRS. PTLFETAL HEART RATE 110 - 160 bpm 152 bpm

CONTRACTION (PTL) NO CONTRACTION MILD TO MODERATE CONTRACTION

AMNIOTIC FLUID NORMAL OLIGOHYDRAMNIOS POLYHYDRAMNIOS

Per milliliters 500 to 1,000 ml < 500 ml > 2,000 ml

Amniotic Fluid Index by Ultrasound

8 - 18 cm <5-6 cm> 20 – 24 cm

DAY 01 13.08.12

PREGNANCY UTERINE 31 WEEKS AND 1 DAY AOG BY FETAL BIOMETRY SINGLE, LIVE IN CEPHALIC PRESENTATION GOOD CARDIAC ACTIVITY POSTERIOR PLACENTA, GRADE II, NO PREVIATotal AFI: ANHYDRAMNIOSBPP = 6/8

DAY 03 15.08.12

AMNIOTIC FLUID VOLUME BELOW THE 3RD PERCENTILETotal AFI: 7.1 cms OLIGOHYDRAMNIOSBPP = 6/8The umbilical artery pi is increased (1.71) suggestive of INCREASE UTEROPLACENTAL RESISTANCE (probably secondary to GDM) which may possibly lead to INTRAUTERINE GROWTH RESTRICTION.

LABORATORY RESULT REFENCE RANGE

Urinalysis LeucocytesPus cellsOthers

1+10-15/hpf0-1/hpfFUNGAL HYPAE present

Cervico vaginal SwabPus cells:Ep Cells:Morphology

4-6/oif2-4/oifLactobacilli, plenty; CANDIDA PRESENT; No clue cells, Negative for gonococci

LABORATORY RESULT REFENCE RANGECBC

HGBHCTPLT

11.3g/dl35.4 %289

11.2-15.7 g/dL34.1-44.9%182-369/UL

Blood Group A

Rh Type Positive

PT 13.3 sec 10.9 – 16.3 Seconds

APTT 30.4 sec 27 – 39 Seconds

LABORATORY RESULT REFENCE RANGEAntibody Screen Negative NegativeUrine culture and sensitivity

No growth seen after 48 hours of incubation at 37°C

Vaginal Swab culture

No growth seen after 48 hours of incubation at 37°C

HBsag Negative Negative

C-Reactive Protein Negative Negative

BLOOD GLUCOSE MONITORINGDATE BREAKFAST LUNCH DINNER

TIME OF

MEAL

PRE-BS POST-BS 2HRS

TIME OF

MEAL

PRE-BS POST-BS 2HRS

TIME OF

MEAL

PRE-BS POST-BS 2HRS

13/08/12 Upon admission 71mg/dl 1115H 93mg/dl 192mg/dl14/08/12 116mg/dl 173mg/dl 1740H 136mg/dl 152mg/dl15/08/12 0830H 109mg/dl 121mg/dl 1330H 110mg/dl 131mg/dl 1935H 79mg/dl 91mg/dl16/08/12 78mg/dl 1200H 77mg/dl 112mg/dl 2000H 85mg/dl 124mg/dl17/08/12 90mg/dl 1130H 103mg/dl 110mg/dl18/08/12 2000H 145mg/dl19/08/12 1200H 123mg/dl 2000H 109mg/dl20/08/12 0400H 100mg/dl

A fasting blood glucose level below 95 to 100 mg/dL and2 hour postprandial level below 120mg/dL

*Maternal & Child Health Nursing – Lippincot, 2007.

Patient has mild fluctuation in blood sugar level. Patient does not need insulin; just diet control. Plan: BSR x 8hourly, HBaIC, TSH

Internal Medicine

CONSULTATION

RESULT REFERENCE

Glycosylated Hemoglobin (HBa1C)

3.5% Diabetics:4.0-6.02 Good control

6.3-7.9 Satisfactory Control>7.9 unsatisfactory control

TSH 1.35uIU/ml Euthyroid = 0.25 – 5.0 uIU/mlHypothyroid more than 7.0

uIU/mlHyperthyroid less than 0.15

uIU/ml

MEDICATIONNAME OF DRUG ACTION DOSAGE ROUTE/

FREQUENCY

Dexamethasone Corticosteroid 12mg IM x 2 dosesAmpicillin Antibiotic 500mg IV Q6 x 48°Erythromycin Antibiotic 250mg PO q6Clotrimazole Antifungal 100mg Vaginal Supp

OD HS x 6 days

Nifedipine Calcium Channel Blocker

10mg PO Stat then TID

Ferrous Sulphate

Iron Supplement

100mg PO OD

Calcium Citrate Calcium Supplement

600mg PO OD

Anesthesia

CONSULTATION

Pre-Anesthetic Visit done. For cardiac consultation.

Cardiac CONSULTATIONECG REPORT 2D ECHO REPORT NT-pro BNP

Sinus Tachycardia (after Nifedipine) otherwise WNL

SWM: WNLEF 70 – 75 %All Valve: WNLPASP 20 mmHgPeri cardium: WNL

51 pg/mLReference:< 75 Years : = < 125> 75 Years : = < 450

PLANNo specific intervention right now from cardiology side.

Low risk for cardiac arrest, no objection for operation if you need to do.

If you can decrease dose of Nifedipine to decrease tachycardia

COLLABORATION

Neonatologist & Neonatal Intensive Care Unit Staff for

Neonatal care/resuscitation.

TOPIC PRESENTATION

Preterm Labor (PTL) is defined as regular contractions associated with cervical changes after 20 weeks’ gestation and prior to 37 completed weeks of gestation.

It is the second, only to birth defects, as the leading cause of neonatal mortality.

It occurs in up to 12 % of all pregnancies and is the most frustrating clinical dilemmas in obstetrics.

Molecular Mechanism of PTL

1. Premature activation of the maternal or fetal HPA axis

2. Decidual and amniochorionic inflammation

3. Decidual hemorrhage

4. Pathologic uterine distention

ANATOMY & PHYSIOLOGY

Hypothalamic-Pituitary-Adrenal Axis

CortisolAldosteroneSex hormone

& DHEA

AdrenalineNoradrenaline

PRETERMLABOR

Current Pregnancy

complications

Fetal anomalyHydramniosAbdominal

surgery Previous LSCS

InfectionPROM

UTI

UNKNOWN CAUSES

OTHER:

StressOccupational factors

MATERNAL SYSTEMIC DISEASEHeart

Gestational Diabetes

BEHAVIORAL & ENVIRONMENT:Poor NutritionLate Prenatal care

DEMOGRAPHIC DATA: MATERNAL AGE < 17 & > 35

RISK FACTOR OF PTL

MATERNAL STRESS (Genital infections, Maternal factors/ Systemic Disease)

MATERNAL STRESS (Genital infections, Maternal factors/ Systemic Disease)

FETAL STRESS (Uteroplacental insufficiency)

FETAL STRESS (Uteroplacental insufficiency)

Activation of maternal HPA axis Activation of fetal HPA axisACTH Adrenocorticotropic hormone

CORTISOL ADRENAL

DHEAS

PLACENTA MEMBRANESESTROGEN

MYOMETRIAL Oxytocin Receptors, Prostaglandins, Myosin Light Chain Kinase, calmodulin, gap junctions

RUPTURE OF MEMBRANCES

CRH

PROSTAGLANDINS

CERVICAL CHANGE

CONTRACTIONS

DECIDUAPLACENTAMEMBRANES

COX-2 INPGDH IN

AMNIONCHORION

Vaginal Examination

Transvaginal Cervical Ultrasound

Clean-catch Urine For Culture, Vaginal And Cervical Culture

Fetal Fibronectin (Ffn)

External Fetal Heart Monitor or Cardiotocogram

Fetal Ultrasound Amniocentesis

UTERINE CRAMPS UTERINE CONTRACTIONS OCCURING AT INTERVALS OF 10 MINUTES LOW ABDOMINAL PAIN OR PRESSURE (PELVIC PRESSURE) DULL LOW BACKACHE

INCREASE OR CHANGE IN VAGINAL DISCHARGE

FEELING THAT BABY IS PUSHING DOWN ABDOMINAL CRAMPING WITH OR WITHOUT Nausea, Vomiting OR DIARRHEA

NURSING INTERVENTION1. Educate mother regarding signs and symptoms of PTL and about steps to be taken to counteract the process.

2. Discuss aspects of a healthy diet and adequate maternal weight gain during pregnancy.

3. Institute bed rest with patient in side lying position that will enhance placental perfusion.4. Early therapy options like abstinence from intercourse and orgasm.

NURSING INTERVENTION5. Obtain laboratory studies including CBC, hgb and hct, serum electrolytes. Obtain clean-catch urine for culture, vaginal and cervical cultures, and fibronectin as ordered.

6. Monitoring vital signs, fetal heart rate, and uterine activity as a baseline.

7. Initiating hydration measures and monitoring intake and output.

MANAGEMENT

Early Education

Prevention

Limiting Neonatal Morbidity

Preconception Care

Baseline assessment of health and risk Pregnancy planning and identification of barriers to care. Adjustment of prescribed and over-the-counter medications that may pose a threat to the developing fetus. Nutritional counseling as needed. Screen for chronic diseases.

Genetic counseling as indicated.

Antepartum Treatment

Educate patient regarding signs/symptoms of PTL.

Instruct patient and provide resources for lifestyle modification.

a. Discuss aspects of a healthy diet and adequate maternal weight gain during pregnancy.Early therapy options include bed rest, hydration, and abstinence from intercourse and orgasm

Tocolytic TherapyAgent Mechanism of

ActionDose Side-effects Nursing Action

Nifedipine Calcium Channel Blocker

Loading: 20mg stat then repeat after 30minutes or until uterine activity subsidesMaintenance:10mg TID

HYPOTENSION TACHYCARDIA, headache, flushing

BP monitoring Q15minutes for 1 hourHold the dose:For SBP < 90Or DBP < 60 Hr 100 bpm

Other Tocolytic Drugs which are not used due to Maternal/Fetal adverse Effect

Medication Maternal/Fetal Side-effectsTerbutaline/Bricanyl B2 Adrenergic Receptor Agonist

PULMONARY EDEMA is a well-documented complication, usually associated with aggressive intravenous hydration.

Indomethacin Prostaglandin Inhibitor

Decrease fetal urine output resulting in Oligohydramnios & Premature close of fetal ductus arteriosus which result to fetal pulmonary Hypertension.

Atosiban Oxytocin Inhibitor

Nausea was significantly increased after injection administration.

Antibiotic Therapy

Antibiotic DoseAmpicillin Loading: 2gram IV

Maintenance: 1 gram IV Q6 for 48hours

Erythromycin 250mg Q6 until 10 days

General Contraindications to Tocolytic Therapy

1. Category III FHR Patterns2. Intra-amniotic infection3. Eclampsia or severe preeclampsia4. Fetal demise5. Fetal maturity6. Maternal hemodynamic instability7. Severe bleeding of any cause8. Fetal anomaly incompatible with life9. Severe IUGR10. Cervix dilated more than 5cm

Acceleration of Fetal Maturity

Agent Mechanism Of Action

Dose Side-effects Nursing Implications

Dexamethasone CorticosteroidTo hasten fetal lung maturity

12mg IM Q12 x 2 doses

irritation at the injection site, tachycardia

Explain the purpose of the drugMonitor v/s and fetal heart rate

Postponing delivery for administration is an option because it takes

about 24 hours for the Dexamethasone to have an effect. The effect last approximately 7 days.

Acceleration of Fetal Maturity

Agent Mechanism Of Action

Dose Side-effects Nursing Implications

Survanta Lung surfactant

4ml/kg intratracheally; four doses in first 48 hours of life

Transient bradycardia, rales

Suction infant before administration.Assess RR, Rhythm, Arterial blood gas, and color before administration.Ensure proper ET tube placement before dosing.Do not suction ET tube for 1 hour after administration, to avoid removing drug.

Complications

Prematurity and associated neonatal complications, such as lung immaturity:

Intraventricular Hemorrhage (IVH) Respiratory Distress Syndrome (RDS) Patent ductus arteriosus (PDA)

Necrotizing enterocolitis (NEC)

Complications of Preterm Labor

Premature Labor can’t be halt will lead to Preterm Delivery

PRIORITIZATION OF NURSING PROBLEMS

1. Risk for injury maternal/fetal related to preterm labor and tocolytic therapy.

3. Activity intolerance related to prescribed bed rest or decreased activity secondary to threat to preterm labor

2. Deficient Knowledge: Preterm labor Prevention related to unfamiliarity with Preterm Labor signs/symptoms and prevention)

PRIORITIZATION OF NURSING PROBLEMS

4. Deficient Diversional activity related to inability to engage in usual activities secondary to attempts to avoid PTL & PTB

6. Anticipatory grieving related to preterm labor and birth

5. Anxiety related to medication and fear of outcome of pregnancy

PRIORITIZATION OF NURSING PROBLEMS

7. Risk for Complications secondary to tocolytic therapy

8. Compromised Family Coping secondary to hospitalization

NURSING CARE PLAN

ASSESSMENTNURSING

DIAGNOSISGOALS & DESIRED

OUTCOME

NURSING INTERVENTIONRATIONALE EVALUATION

SUBJECTIVE:“ I feel a sudden contraction” as verbalized by the patient

OBJECTIVE:1. Continued

uterine contraction

2. Facial mask of pain

3. Irritability

V/S taken as follows:

BP: 120/70mmHg

PR: 80 bpmRR: 20 cpmTemp.: 36.9◦CFHT: 152bpm

Cervix: 1cm dilated, 50%

Effacement, Station: -3

Cephalic Position

Risk for Injury maternal /fetal related to preterm labor and tocolytic therapy.

Within 12 hours of nursing intervention, patient’s contraction halt after treatment with tocolytic and fetal heart rate remains within acceptable parameters.

1. Positioned patient on left side as much as tolerated. Change to right side if client becomes uncomfortable – avoid supine position.

2. Explain all procedures and equipment to patient and significant other.

3. Attached external fetal heart rate monitors for continuous evaluation of contractions and fetal response.

Position facilitates uteroplacental perfusion.

Client and significant other may be experiencing high anxiety and need repeated explanation.

Uterine and fetal monitoring provides evidence of fetal well-being.

After 12 hours of nursing intervention, the goal was fully met as evidenced by:Cessation of uterine contraction after treatment with tocolytic.Fetal heart rate remains within acceptable parameters.

ASSESSMENTNURSING

DIAGNOSISGOALS & DESIRED

OUTCOME

NURSING INTERVENTION RATIONALE EVALUATION

4. Made contact with ultrasound personnel as per doctors order.

5.Extracted blood for laboratory studies such as CBC. Obtained clean-catch urine for culture, vaginal and cervical culture.

6. Inserted IV line and begin IV fluid therapy as doctors’ order.

7.Administered betamethasone as prescribed.

An ultrasound can document fetal health and cervical dilation.

Assessment provides a baseline for future comparison.

IV fluid improves hydration, which may help to minimize contractions.

This synthetic cortisol can accelerate fetal lung maturity by stimulating surfactant production.

ASSESSMENTNURSING

DIAGNOSISGOALS & DESIRED

OUTCOME

NURSING INTERVENTION RATIONALE EVALUATION

8. Administer antibiotics, as indicated.

9. Initiate tocolytic therapy, as ordered.

10. Checked patient’s vital signs closely, every 15 minutes. Assessed for chest pain and dyspnea.

11. Checked fetal heart rates and pattern.

In the event of PROM, antibiotics may be used to prevent/reduce risk of infection.

Helps reduce myometrial activity to prevent/delay early delivery.

Maternal pulse over 120 beats per minute or persistent tachycardia or tachypnea, chest pain, dyspnea, or adventitious breath sounds may include impending pulmonary edema.

Fetal tachycardia or late or variable decelerations indicate possible uterine bleeding or fetal distress, which requires emergency birth.

NURSING HEALTH TEACHING Educate the patient about the importance of continuing the pregnancy until the term or fetal lung maturity.

Encourage the need for compliance with a decrease activity level or best rest, as indicated.

Teach the patient the importance of proper nutrition and the need for adequate hydration.

Instruct the patient not to engage in sexual activity if diagnosed with PTL.

NURSING HEALTH TEACHING Teach the patient the signs and symptoms of infection and to report them immediately. When preterm labor occur:

Lie down on left side for 1 hour Drink 2-3 glasses of water or juice Palpate for contractions If no contractions, assume light

activity, if symptoms comes back, need to notify health care professionals

Empty bladder to relieve pressure on the uterus

CONCLUSION

Presented a case of a 40 y/o G2P1 Pregnancy Uterine 31 3/7 weeks with 10-15 pus cells & Candida present on Cervico vaginal swab are considered maternal infection that plays a potential etiologic role in preterm labor therefore an administration of antibiotic therapy will be given to prevent perinatal transmission.

On conservative management such as antenatal screening and close fetal antenatal surveillance (biophysical profile with Doppler velocimetry every 3 days)

CONCLUSION

High Risk Pregnancy with Preexisting Illness like Diabetes and Heart Disease needs a special care provided by the Internist, Cardiologist, Anesthesiologist, OB/Gyne & Sonologist & Neonatologist.

On tocolytic therapy such as Nifedipine, administration of Corticosteroid Dexamethasone for acceleration of lung maturity and provision of neonatal care.

Rendered close observation including fetal status and labor progress.

CONCLUSION

Nurses’ role in providing education to the patient about the importance of continuing the pregnancy until term or fetal lung maturity.

However, on Day 04 CTG shows early deceleration and labor progresses. Patient underwent REPEAT LSCS due to FETAL DISTRESS (persistent fetal bradycardia) to a stillborn infant with MULTIPLE CONGENITAL DEFECTS, AMBIGOUS GENETALIA.

Wolters Kluwer & Lippincot Williams & Wilkins. Lippincot Manual of Nursing Practice, 9th edition, page 1330-1333, 2010.

Pillitteri, Adele. Maternal & Child Health Nursing, 3rd ed.Philadelphia: Lippincott, 1999.

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