precipitous delivery case study kimberli marchion & meghan

Running Head: PRECIPITOUS DELIVERY CASE STUDY 1

Precipitous Delivery Case Study

Kimberli Marchion & Meghan Shenot

Kent State University


Precipitous Delivery Case Study

Introduction

We chose to do our paper on HP because she had a very interesting case with several

high risk complications that needed to be monitored during the postpartum period. She is a

thirty-one year old female that was admitted into the hospital in labor. HP is gravida four, para

four, and living four. She is currently married to GP, which is the father of all four of her

children. The family currently is insured by Buckeye Insurance; however, the client stated that

she may apply for Women, Infants, and Children (WIC) because she is a stay at home mom with

four children all of which are on her husband’s income.

HP had a vaginal delivery on March 30th

, 2011. This delivery was high risk because the

client had a cerclage in place at the time she went into labor. The cerclage was not able to be

removed before delivery because the client experienced a precipitous birth. HP delivered a baby

girl at 0516. The little girl weighed four pounds, seven ounces. HP’s infant was taken to the

Neonatal Intensive Care Unit (NICU) because of signs indicating respiratory distress at time of

birth.

History

The client was admitted for a precipitous birth. A precipitous birth is a very fast delivery

of an infant. During a precipitous birth, the mother may be instructed to blow to decrease the

pressure that causes one to feel the urge to push. During a precipitous birth, it is very important

to massage the perineum to increase the stretching of the vagina and decrease the lacerations.

Precipitous births significantly increase the risk for hemorrhage during and after the birth and

lacerations during the birthing process (Davidson, London, & Wieland Ladewig, 2008). HP was

a 31-year-old Christian and did not seem to want to discuss her religion. HP has a high school


education and she is a stay at home mom of four children. She is not a smoker or a drinker and

denies substance abuse. The family has Buckeye Insurance. HP’s husband works at Mistra’s.

She had no significant medical or surgical history, other than her gynecological history, which is

mentioned later. Her father had been diagnosed with diabetes mellitus, but passed away several

years ago.

Other than the precipitous birth, the mother also had a cerclage in place during the time

of the birth. Having a cerclage in place during birth is very serious and can cause a great deal of

damage to the cervix of the client. A cerclage is placed in the cervix late in the first trimester or

early in the second trimester to prevent a precipitous birth. Having a cervical cerclage in place

will normally keep the baby in the uterus longer so that the baby can be born full term

(Davidson, London, & Wieland Ladewig, 2008); however, in this case it did not work. The

infant pushed past and around the cerclage according to the report we had obtained that morning.

It is very rare for an infant to push past the cerclage and it is very dangerous. By pushing past

the cervical cerclage, the cervix can be torn. While assessing the client every hour to two hours,

her bleeding began to decrease as the hours past in the postpartum period. By the end of the

shift, her bleeding was significantly lighter and was light to moderate. According to the reports

and the charts, there were no tears during birth and the cervix was not damaged.

OB History

HP is gravida four, para four, zero abortions, and living four. All four of her children

were born vaginally. The client stated that she had an epidural for the first three children;

however, for this child she dilated too fast and was not able to be medicated. HP’s last monthly

period was July 7, 2010. According to the charts, her estimated date of delivery was May 3,


2011. HP’s infant was a girl and she was born at 35 weeks and one day. The mother has a

history of gestational diabetes. While discussing the history of gestational diabetes with HP, she

stated that she was able to control her diabetes by her diet and did not need insulin. Her first two

pregnancies went smoothly according to HP. Every week she was given 17P Progesterone IM

into the gluteal. She had a cerclage placed during her third pregnancy to prevent a precipitous

birth and she was induced at 34 weeks due to placental failure or Intrauterine Growth Restriction

(IUGR) according to the client’s charts. This is where the environment of the uterus is not

sufficient for the baby and the baby is small for his or her gestational age. With the third

pregnancy, the client was able to have the cerclage removed and no damage was caused to the

mom or baby. HP does not have a history of STIs. When asked if she had ever been to prenatal

classes she replied that she had not.

Prenatal Laboratory Data

Prenatal Test Norms Patient Results Analysis

Type & Rh + or - + Mom and baby were

both Rh+ and this is a

normal test result.

There were no

concerns with needing

to give any Rhogam

injections.

Hemoglobin &

Hematocrit

38-47 % and 12-16

g/dL

36.2% and 12.7 g/dL The patient’s

hemoglobin was

within the normal

range, but her

hematocrit level was

low. This is normal in

pregnancy to have a

decreased level

because there is extra

fluid in the blood. It

is also normal to have

low levels due to

blood loss after

delivery. This could


also be due to her

precipitous delivery

because there is an

increased risk of

bleeding with this.

VDRL/RPR NR NR This was a normal test

result.

Rubella Immune 1 mm (immune) Since the patient was

immune, no rubella

vaccine was needed.

Urine C & S Clear + E. coli This is not a normal

result. It was not

stated why patient had

E. coli in urine, how

long it had been

present or if it had

been treated.

Sickle Cell Negative Not obtained This laboratory value

was not in the chart.

Chlamydia/Gonorrhea Negative/Negative Negative/negative This was a normal test

result.

PAP test Normal Normal This was a normal test

result.

Triple Screen AFP- 1-4 g/L

Hcg-up to 500,000

IU/24 hr

Estriol-2-12 ng/mL

Not obtained This laboratory value

was not in the chart.

1 hr Glucose

Tolerance

< 135 mg/dL 143 mg/dL This value was

abnormal because she

had gestational

diabetes. She then

went on to have a 3

hour glucose tolerance

test.

1 hr Glucose Fasting:

2 hr

3 hr

<65 mg/dL

<155 mg/dL

<140 mg/dL

*If patient exceeds

these values, it

indicates gestational

diabetes.

94 mg/dL This value was

abnormal because she

had gestational

diabetes. Her two and

three hour values

were not found in the

chart, although the

mother stated that she

failed her three hour

glucose test.

(Cavanaugh, 2009)


Diagnostic Tests

Test Date Norms Patient Findings

Ultrasound March 16th

The patient exhibited

normal findings for

this category.

Placenta, cord and

amniotic fluid growth

FFN March 16th

Negative The patient had

negative findings.

This indicates that she

does not have the

probability of delivery

within one week

(Venes, 2009).

Prenatal Medications

Medication

s

Dose,

route

Mechanis

m of action

Indications

for use

Possible side effects Nursing

Responsibiliti

es

17P

Progesteron

e

Client

stated that

she

received a

shot in

the

gluteal

muscle

weekly

during

her

pregnanc

y. She

did not

state the

dosage

and

according

to Davis’s

Drug

Guide for

Nurses,

there was

According

to the

client’s

chart and

the client

herself, the

17P

Progesteron

e was given

because of

placental

insufficienc

y during

her

pregnancy.

By getting

progesteron

e weekly,

the chances

of her

having a

term baby

were

Placental

insufficienc

y

It can be

given

weekly at

16-20

weeks of

gestation

and

continue

until

delivery

“CNS: depression.

EENT: retinal

thrombosis. CV:

PULMONARY

EMBOLISM,

THROMBOEMBOLIS

M, thrombophlebitis.

GI: gingival bleeding,

hepatitis. GU: cervical

erosions. Derm:

chloasma, melasma,

rashes. Endo:

amenorrhea,

breakthrough bleeding,

breast tenderness,

changes in menstrual

flow, galactorrhea,

spotting. F and E

edema. Local: irritation

or pain at IM injection

site. Misc: ALLERGIC

REACTIONS

INCLUDING

Assess client

for signs and

symptoms of

fluid retention

while

receiving

Progesterone.

-instruct client

to report any

signs of

vaginal

bleeding.


not a dose

listed that

was given

weekly to

the client.

increased. ANAPHYLAXIS AND

ANGIOEDEMA,

weight gain, weight

loss.”

Deglin &

Vallerand,

2009)

Labor and Delivery Data

While looking in the charts, there was not much information in regards to the labor and

delivery of our client. Her due date was May 30th

, 2011; however, she went into labor on March

30th

, 2011. She came in already in labor and was not able to receive an epidural or pain

medications because the staff had to prepare for delivery of the infant. This was a precipitous

birth and the client stated that from the time that her contractions began to the time of the birth of

her baby girl was less than two hours. While looking through the chart, contraction patterns

rupture of membranes (ROM), progression of dilation, effacement, station, amniotic fluid and

membranes were not charted at this time. The client had a vaginal delivery and it was not

assisted by vacuum or forceps. She stated that the staff was very concerned about her well-being

and the well-being of her infant; therefore, she felt that preparations were rushed. Medications

and IV fluids during labor were not found in the chart at this time, as well as the intake and

output of the mother.

Nursing Diagnoses

Diagnosis As Evidence By Goal Interventions

with rationale

Evaluation

Risk for

complications of

bleeding related

-Possible tearing

of the cervix

during childbirth

STG: The goal is

to decrease the

amount of

-Monitor fluid

status to ensure

that the patient

The short term

goal was met;

the patient had


to trauma during

pregnancy and

birth

“Describes the

person

experiencing or at

high risk to

experience a

decrease in blood

volume”

(Carpentio-

Moyet, 2010, p.

845).

(Educational)

-Cerclage was not

removed before

birth of baby

-Precipitous birth

of baby

-Saturated three

peri-pads within

an hour and a half

in the morning

-Hematocrit level

of 36.2 (which is

low)

postpartum

bleeding during

shift by making

sure the fundus is

firm and midline

and that the

patient is voiding

sufficiently.

LTG: The goal is

for the patient to

have a decreased

amount of peri-

pads and the

patient only needs

to change them

every 2-3 hours

(as compared to 3

in one hour) by

discharge.

is voiding

adequately

(Davidson,

London &

Ladewig, 2008,

p. 1054).

-Assess bleeding

every hour by

assessing peri-

pads and

applying ice

packs when

needed. “Cold

applications are

therapeutically

prescribed in

order to provoke

vasoconstriction.

This constriction

reduces blood

circulation in the

area of

application,

affording relief

of pain caused

by decreasing

pressure on

nerve endings. It

is also used to

decrease

hemorrhage…”

(Hasegawa,

2009, p. 198)

-Apply warm

water with peri-

bottle and tucks

pads to patient’s

perineal area

after each void.

“Perineal care

after each

elimination

(urination or

defecation)

cleanses the

perineum and

a significant

decrease in

bleeding. The

fundus was

firm and one

below the

umbilicus.

Fluids were

monitored and

discontinued

once the

patient’s

bleeding

decreased.

Bleeding was

assessed every

hour to two

hours during

the shift and

there was a

significant

decrease in the

amount of

blood found on

the peri-pads.

The patient

was educated

on the bleeding

risks and signs

and symptoms.

Tucks pads

were applied

per patient’s

request after

each void.

The long term

goal was

probably met.

By the end of

shift, the

patient was

changing peri-

pads every two

hours and pads

were not


helps promote

comfort”

(Davidson,

London &

Ladewig, 2008,

p. 1078).

-Educate patient

on signs and

symptoms of

increased

bleeding and

what to do. It is

important to

educate the

patient on the

signs and

symptoms of

increased blood

loss so

symptoms are

recognized and

treated early

before they

become worse

(Davidson,

London &

Ladewig, 2008,

pp. 1164-1165).

saturated; there

was light to

moderate

lochia rubra.


with rationale

Evaluation

Disturbed Sleep

Pattern related to

frequent

awakenings

secondary to

hospitalization

“This is a state in

which a client

experiences a

change in the

quantity or

quality of one’s

rest pattern that

causes discomfort

or interferes with

-Baby in Neonatal

Intensive Care

Unit (NICU)

-Mom

breastfeeding

every 3 hours

-Mom states “I’m

really tired, could

you come back

later to do that?”

-Traumatic birth

of baby adds to

stress

-Bleeding had to

be assessed every

one to two hours

STG: The patient

will report an

increase in

rest/sleep

throughout shift.

LTG: At follow-

up visit, patient

will report

receiving an

adequate amount

of sleep even

though

breastfeeding her

infant.

-Organize

procedures to

minimize

disturbances

during sleep

period.

“Strategies in

any postpartum

setting that can

improve the

mother's sleep

effectiveness

and reduce sleep

disturbance may

lead to improved

mental and

The short term

goal was met

because the

patient was

able to get an

hour and a half

nap before the

shift was over.

Nursing

activities were

grouped

together with

assessments to

provide

adequate time

for mom to


desired lifestyle”

(Carpentio-

Moyet, 2010, p.

602).

(Psychological)

physical well-

being and to

improved

enjoyment of

motherhood”

(Hunter,

Rychnovsky &

Yount, 2009)

-Pull curtains

and close door

to the room to

minimize noise.

“The

environment

should mimic

nighttime, with

lights dimmed

and quiet

maintained”

(Black &

Hawks, 2009, p.

415) to promote

sleep.

-Administer pain

medication to

improve comfort

level as needed.

“If the client is

in pain,

analgesics rather

than sleeping

medications

should be given.

Clients in pain

do not sleep

restfully” (Black

& Hawks, 2009,

p. 415).

-Provide mother

with breast

pump in her

room so breast

milk can be

taken to NICU

and the mother

does not need to

rest. Curtains

and door were

kept shut

throughout the

shift and pain

medication was

administered

before the

patient rested.

A breast pump

was placed in

the patient’s

room during

shift so she

was able to

pump in the

room, rather

than in NICU.

The long term

goal cannot be

measured at

this time

because it will

be reported at

her follow-up

visit.


make a trip to

NICU to feed

the baby every

two to three

hours. This was

discussed during

lecture. We

discussed the

advantages of

breast pumps

and how others

can share the

responsibility of

feeding the

infant to allow

the mother to

rest.

Description of Head-to-Toe Assessment

The assessment was performed at 0745. While obtaining the clients vital signs,

everything was normal except for her blood pressure. She had a temperature of 97.6 F (36.4 C),

pulse of 70 beats per minute, respirations of 18 per minute, and a blood pressure of 150/77. The

client was asked if she had a history of hypertension and she stated that she had not; however,

the past week her blood pressure had been higher than normal. Her blood pressure was

reassessed and was 138/80 by the end of the shift. She stated that she had a pain of two out of

ten and that her pain was a mild cramping in her stomach and her bottom was sore; no

hemorrhoids were present. While listening to her lungs, her breath sounds were clear anteriorly

and posteriorly. Her capillary refill was less than three seconds. While assessing her legs, she

did not have any swelling present and denied numbness and tingling.

She had a vaginal delivery without any instruments being used to assist in the delivery.

HP did not have an episiotomy or lacerations according to her and her charts. She did not show


any signs of bruising in the perineal area; however, she had moderate to heavy amounts of rubra

lochia present in peri-pads without clots. By the end of the shift, her bleeding decreased

significantly. When asked, the client stated that she had been passing gas and her bowel sounds

were present in all four quadrants. Her fundus was midline and one below the umbilicus

throughout the day. HP stated that she was going to be breast feeding her infant and that she

would be pumping because her baby girl was in the Neonatal Intensive Care Unit (NICU). HP

denied tenderness in her breast or nipples; however, did ask for Lanolin cream for her nipples

around lunch time.

Postpartum Laboratory data

Tests Norms Patient Results Analysis

White blood cell 5-10 mm3 13.73 mm3 (high) This laboratory value

is elevated because it

is a normal response

for the body to

produce more white

blood cells in the final

stages of pregnancy

(Cavanaugh, 2009).

Postpartum Medications

Medications Dose, route Action Indications

for use

Side Effects Nursing

Responsibilitie

s

Acetaminophe

n (Tylenol

regular

strength)

Class:

antipyretic,

nonopioid

analgesic

650 mg= 2

tabs PO q4h

prn for pain,

scale mild

(1-4)

Inhibits the

synthesis of

prostaglandin

s that may

serve as

mediators of

pain and

fever,

primarily in

the CNS

For mild pain

and fever

Hepatic

failure and

hepato-

toxicity are

major side

effects, other

common

include

neutropenia,

rash or renal

failure

Administer

with a full glass

of water, do not

exceed the

maximum

recommended

dose, assess

pain type,

location and

intensity and

assess fever

Benzocaine 1 Inhibit Relief of Allergic Assess type,


topical

(Americaine)

Class: topical

anesthetic

application

of ointment

to perineum

initiation and

conduction of

sensory nerve

impulses

pruritus or

pain with

minor skin

disorders

such as

burns,

abrasions,

insect stings

or bites,

dermatitis,

bruises,

hemorrhoids

or other

forms of skin

irritation

reaction is

major side

effect, but

others

include

burning,

edema,

irritation,

stinging,

tenderness or

urticaria

location and

intensity of

pain and assess

integrity of skin

and mucus

membranes

periodically

Glycerin witch

hazel topical

(Tucks 50%

top pad)

1

application

(rectal pad)

six times a

day prn for

hemorrhoid

discomfort

Contains

witch hazel-

an astringent

that will help

relieve

irritation and

burning due

to

hemorrhoids

Temporarily

relieves

external

symptoms

associated

with

hemorrhoids

such as

itching,

burning or

irritation

None listed Do not exceed

the

recommended

daily dosage,

do not put

directly in

rectum and stop

use if rectal

bleeding occurs

or if condition

worsens or

does not

improve within

7 days

(McNeil, 2011)

Hydrocortisone

-Pramoxine

topical

(epifoam rectal

foam)

Class:

anesthetic

1

application,

foam, rectal,

qid, prn for

hemorrhoid

or perineal

discomfort

Inhibit

initiation and

conduction of

sensory nerve

impulses

Relief of

pruritus or

pain

associated

with minor

skin

disorders

including

burns,

abrasions,

bruises,

insect bites,

dermatitis or

hemorrhoids

Allergic

reaction is

major side

effect, but

others

include

decreased or

absent gag

reflex,

burning,

edema,

irritation,

stinging,

tenderness or

urticaria

Assess type,

location and

intensity of

pain, assess

integrity of skin

and mucus

membranes

periodically

Hydrocortisone 1 Suppress Management No major, but Apply


topical

(Anusol- HC)

Class:

corticosteroid

application

(rectal

suppository)

: 25 mg for

discomfort

normal

immune

response and

inflammation

of inflamm-

ation and

pruritis

associated

with various

allergic or

immuno-

ologic skin

problems

others

include

burning,

dryness,

edema,

allergic

reactions,

irritation,

striae

sparingly as a

thin film to

clean, moist

skin, wash

hands

immediately,

assess affected

skin during

therapy

Ferrous Sulfate

(Feosol)

Class:

antianemic

(iron

supplement)

325 mg= 1

tab po

qdayM, 1

tab PO

bidM

Enters the

bloodstream

and is

transported to

the organs

such as liver,

spleen or

bone marrow

where it

becomes part

of iron stores

Treatment

and

prevention of

iron

deficiency

anemia

No major, but

common side

effects

include

nausea,

constipation,

dark stools,

epigastric

pain, GI

bleeding,

vomiting,

staining of

teeth,

dizziness and

headache

Administer 1

hour before or

2 hours after

meal to

enhance

absorption, take

tablets with a

full glass of

water, assess

nutritional

status and

dietary history,

assess for

constipation or

diarrhea and

monitor

hemoglobin

and hematocrit

Citric Acid Na

Citrate

(Bicitra)

30mL, Soln,

PO

“Converted

to

bicarbonate

in the body,

resulting in

increased

blood pH. As

bicarbonate is

renally

excreted,

urine is also

alkinized,

increasing the

solubility of

cystine and

uric acid.

Neutralizes

gastric acid.

Therapeutic

“Managemen

t of chronic

metabolic

acidosis

associated

with chronic

renal

insufficiency

or renal

tubular

acidosis.

Alkalinizatio

n of urine.

Prevention of

cystine and

urate urinary

calculi.

Prevention of

aspiration

Diarrhea,

fluid

overload,

hypocalcemia

, metabolic

alkalosis

(large doses

only),

hypernatremi

a (severe

renal

impairment),

and tetany

Assess for

confusion,

irritability,

paresthesias,

altered

breathing

pattern, and

tetany

(alkalosis),

monitor for

fluid overload,

monitor

hemoglobin

and hematocrit,

electrolytes,

pH, creatinine,

urinalysis, and

24-hr urine for

citrate, missed


Effects:

Provision of

bicarbonate

in metabolic

acidosis

pneumonitis

during

surgical

procedures.

Used as a

neutralizing

buffer”

doses need to

be taken within

2 hours,

administer

before bed or

30 minutes

after meals,

avoid salty

foods and

increase fluids

to 3000 ml/day

Deglin &

Vallerand,

2009)

Postpartum Procedures & Treatments

Procedure/Treatment Norms Patient Findings

Epifoam Decrease discomfort in

perineal area and increase

healing process

The patient was able to use

this and asked for it and

applied after each void

throughout shift. Patient stated

that using this increased her

comfort level.

Benzocaine or Americaine Decrease discomfort in


healing process






comfort level.

Tucks pads Decrease discomfort in


healing process






comfort level.

Lanolin Promote comfort in

breastfeeding mothers to

prevent cracking

The patient stated that she had

used this previously while

breastfeeding and asked for it

before she was experiencing

any discomfort.

Postpartum Nutritional Assessment Guide


While assessing the mother, she was asked about her pre-pregnant weight and she stated

that she was back to her normal size shortly after birth of her third child before becoming

pregnant again. A current weight and weight before she was pregnant were not obtained. She

stated that she was not able to exercise as much during this pregnancy due to the gestational

diabetes; therefore; she gained a little more weight than normal. HP did not appear to be worried

about losing all of her baby weight right away. She stated that she does not typically snack

throughout the day and that she cooks all of the meals and does all of the grocery shopping for

her family. Her family was not obtaining WIC or food stamps currently; however, she was going

to try and apply after she gets home from the hospital because of being a stay at home mom with

four children and only one income for the household from her husband. A 24-hour diet recall

and fluid intake were not obtained for this patient.

Newborn History

The mother was gravida four, para four, living, four. The maternal prenatal laboratory

results for blood type was A+ and the mother was negative for hepatitis. Her rubella titer

showed that she was immune and her VDRL/RPR was non-reactive. Her Group B Strep culture

was not obtained and the glucose screen tested positive for gestational diabetes. She did not

receive insulin injections during her pregnancy because she was able to modify her diet so

injections were not needed.

Labor-description

The mother stated she began having contractions around four in the morning on March

30th

. She called her husband to come home from work to take her to the hospital. The patient

stated that she could tell the baby was descending while on her way to the hospital. She arrived


at the hospital and was admitted because she was in labor. The patient had a cervical cerclage in

place at the time of vaginal delivery. According to the mother, the baby pushed past the cerclage

while descending through the birth canal, without tearing. The mother was not able to receive an

epidural or pain medication due to the precipitous birth. The mother also stated that from the

time of her contractions to the actual birth was less than two hours.

The gestational age of the baby at birth was thirty-three weeks and five days. The baby

girl weighed four pounds, seven ounces and the Apgar score at one minute was eight and nine at

five minutes. The mother planned on breastfeeding. Respiratory problems are the biggest risk

factors for premature infants because the lungs are the last organ to fully develop in the newborn.

“…lungs are not fully mature and not fully ready to take over the process of oxygen and carbon

dioxide exchange until thirty-seven to thirty-eight weeks of gestation” (Davidson, London &

Ladewig, 2008, p. 943). The infant could also be at risk for cold stress because the skin is

thinner and more permeable to heat loss.

Newborn Physical Assessment

Since the newborn was in NICU, all of the following information was obtained from the

charts in NICU. The first set of vital signs obtained was at 0545, her heart rate was 152 beats per

minute (which is high), 72 breaths per minute (which is high), blood pressure of 59/21 mmHg,

and 99% POX. Her heart rate was reassessed a half hour later and it was 128 beats per minute

and her respirations were also reassessed at this time and they were 32 breaths per minute. The

next full set of vital signs were obtained and were all normal with the exception of her heart rate.

51/23 mmHg was her blood pressure, 29 C, 128 beats per minute was her heart rate (still a little


high according to the NICU policy), 32 breaths per minute, and 97% POX. Respirations were

unlabored and had a regular pattern for an infant.

The infant had a symmetrical face with pink moist mucous membranes. Her palate and

her lips were intact. Nasal passages on infant were patent bilaterally. Her ears were properly

aligned with her eyes. She had short creased neck with skin folds. The infant had soft, flat

fontanels with no sign of tension present. While assessing her heart, no murmur was found and

the rhythm was regular for an infant. Capillary refill was present and less than three seconds.

Pulses on the infant were palpable and all plus two bilaterally. She had a three vessel cord and it

was clamped after birth and beginning to heal. Chest was symmetrical and nipples were aligned

properly. The infant’s clavicle was in place and normal range of motion was present. According

to the charts, the infant had Babinski, palmar, and grasp reflexes present at this time. Bowel

sounds were present in all four quadrants and she was not currently stooling and had not voided.

Newborn Laboratory Data

Tests Norms Patient Results Analysis

Glucose 45-96 mg/dL 82 mg/dL High according to

Aultman’s NICU

policy.

pH 7.18-7.5 mmHg 7.278 mmHg Low according to

Aultman’s NICU

policy. The infant

may have been acidic

due to respiratory

distress at birth. The

infant was also born

preterm, which could

cause immature lungs

increasing the risk for

the infant to be acidic.

pCO2 27-40 mmHg 55.2 mmHg High due to

respiratory distress at

birth. The infant may

have been


accumulating CO2 in

the lungs causing an

increase in pCO2.

pO2 83-108 mmHg 20.0 mmHg Low due to

respiratory distress at

the time of the

infant’s birth.

Decreased oxygen to

the lungs causes a

decrease in pO2.

HCO3 17.2-23.6 mmol/L 25.2 mmol/L High due to

respiratory distress of

the infant at birth.

O2 Sat 85%-90% 26.2% Low due to decreased

respirations at birth.

According to the

NICU charts, at birth,

the infant was in

distress and signs of

grunting were noted

which also explains

why the O2 sat would

be decreased.

Newborn Medications

Infant was in NICU during shift and we did not medicate.

Nursing Diagnoses


with Rationale

Evaluation

Ineffective

Breathing related

to immature lungs

secondary to

prematurity.

“State in which a

client experiences

an actual or

potential loss of

adequate

ventilation related

to an altered

breathing pattern”

-infant was

experiencing

grunting at birth

-respirations were

seventy-two

breaths per

minute and were

labored

-oxygen

saturation was

26.2% according

to the chart

-PCO2 was 55.2

mm Hg and high

STG: The infant

will show no signs

or symptoms of

respiratory

distress including

grunting,

retractions, and/or

cyanosis by the

end of shift.

LTG: The infant

will have a POX

between 95% and

100% on room air

-Suction baby’s

nose and mouth

to decrease the

amount of

secretions

present due to

vaginal delivery.

We know to do

this because of

previous

experience and

lectures.

-Make sure

baby’s

The infant’s

short term goal

was currently

met according

to the charts in

NICU. No

signs of

respiratory

distress were

present during

the last charted

assessment.

The infant’s


(Carpentio-

Moyet, 2010, p.

514).

(Physiological)

according to the

chart

-PO2 was 20 and

low according to

the chart

-pH was 7.28

(which is low and

acidic according

to the chart)

and in open top

crib before being

admitted to the

Labor and

Delivery Unit to

stay with mom.

temperature

stays regulated

because heat

loss is a major

problem for

preterm infants

and the infant

needs to be

monitored

closely because

this can cause

respiratory

distress in the

infant

(Davidson,

London &

Ladewig, 2008,

p. 943).

-Monitor

respirations and

pattern of

breathing every

hour or as

needed due to

possible cold

stress of

premature infant

and infant

possibly not

having fully

mature lungs

(Davidson,

London &

Ladewig, 2008,

p. 943).

-Administer

“supplemental

oxygen” (Yoder,

Gordon, &

Barth, 2008, pp.

pp.814-822) if

breathing strays

from the normal

range because

preterm infants

don’t have fully

long term goal

was partially

met; however,

the infant had

not been

moved from

the incubator to

an open top

crib. Since the

infant had not

been

transferred to

an open top

crib, this is not

a true

respiratory

assessment.

The incubator

provides a

warm

environment

for the child

with only slight

temperature

changes, which

allows the

infant to

breathe easily.

According to

the chart at the

end of the shift,

the oxygen

saturation was

97% on room

air; respirations

were thirty-two

breaths per

minute and

were regular

and unlabored.


mature lungs

and they

sometimes are

not ready to

breathe properly

on their own

(Davidson,

London &

Ladewig, 2008,

p. 943).


with Rationale

Evaluation

Risk for

complications of

Metabolic

Dysfunction

related to preterm

infant.

“Describes a

person

experiencing or at

high risk to

experience a

blood glucose

level that is too

low or too high

for a metabolic

function”

(Carpentio-

Moyet, 2010, p.

867).

(Nutrition)

-Mother with

history of

gestational

diabetes

-Mother had an

elevated one hour

glucose level of

143 mg/dL

-Mother stated “I

failed my three

hour glucose

test.”

-Baby was born

pre-term

-Baby’s glucose

level at birth was

eighty-two, which

was high for a

pre-term baby

according to

Aultman’s NICU

policy

STG: Maintain

infant’s blood

sugar within the

normal range for

preterm infant

throughout shift.

LTG: At follow

up visit, mom will

state that the baby

is tolerating

feedings well

every 2-3 hours

and glucose has

been maintained

within the normal

values for an

infant.

-Check infant’s

glucose

measurement

prior to feeding

or as needed

because infants

that were born to

a mother with

gestational

diabetes are at

an increased risk

for

hypoglycemia

after birth

because of being

disconnected

from the

mother’s blood

and glucose

supply

(Davidson,

London &

Ladewig, 2008,

p. 452).

-Check for signs

and symptoms

of hypoglycemia

and

hyperglycemia

as needed.

Hypoglycemia

is common for

the infant of a

mother with

The short term

goal was not

currently met.

The NICU

nurses were

obtaining

another

glucose

reading before

the baby’s next

feeding at the

end of the shift

and results

were

unavailable at

that time.

The long term

goal has not

been met. This

goal will be

assessed at

next visit with

physician.


GDM; however,

this infant had

increased

glucose levels

according to

Aultman’s

NICU;

therefore, the

baby will need

to be monitored

for

hyperglycemia

(Davidson,

London &

Ladewig, 2008,

p. 452).

-Monitor

infant’s bilirubin

every four hours

because infants

that are born to a

mother with

GDM have

increased

chances for

hyper-

bilirubinemia

(Davidson,

London &

Ladewig, 2008,

p. 452). This

can be done by

pressing down

on the infant’s

nose or chest to

assess whether

or not the skin

turns a yellow

color when

pressure is

applied.

-monitor

infant’s

respirations

because “high

fetal insulin


levels also

contribute to

respiratory

distress

syndrome in

which the

enzymes needed

for surfactant

production are

inhibited.

Surfactant is a

lining that coats

the lungs and

allows newborns

to breathe when

they are born

(Bicknell,

2008).

Conclusion

There were several aspects about the patient that were not considered. This was due to

the fact that there was limited information in the chart. This left many factors unknown such as

additional risk factors. Also, since the birth went so quickly, there was not much information

about the infant because she was transported to NICU shortly after delivery. It was difficult to

obtain information on a patient from another unit and information that was charted by other

nurses. The chart did not mention the reasons the patient had risky labors for her last two

children, but not her first. The patient also stated that she did not know why she had placental

insufficiency and why she needed a cerclage because she did not have problems with that in her

first two pregnancies. For her third and fourth child, she had gestational diabetes and the baby

was born prematurely. Her previous cerclage had been placed during her pregnancy of her third

child due to placental insufficiency and being at risk for preterm delivery. For this pregnancy,

she had gestational diabetes and the baby was also delivered prematurely. She had even more


risks due to the fact that she had a cerclage in place that had needed to be removed before the

birth of the child, which was not.

The patient is also at risk for postpartum depression. Since she is on Buckeye insurance,

it is possible that the patient’s family may have financial issues. The baby was also having

problems and was sent to NICU, which also puts her at risk for depression. She stated that she

did not want to have more children since her last pregnancy had been so difficult, therefore, birth

control options should have been discussed. If she did have any future pregnancies, she would

be at risk for having gestational diabetes and premature, precipitous labor. Since she has had

gestational diabetes with her last two pregnancies, she needs to be monitored every two years

because she is at risk for developing diabetes mellitus in the future.


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precipitous delivery case study kimberli marchion & meghan

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