UNIVERSITY OF PERPETUAL HELP SYSTEM OF LAGUNA DR. JOSE G. TAMAYO MEDICAL UNIVERSITY STO. NIO, BIAN, LAGUNA COLLEGE OF NURSING

(Case study)In partial fulfillment of the requirements in NCM 102 submitted by: BSN- 2B ACADEMIC YEAR 2010-2011

Almacen, Bryan Joseph V.

Buenavista, Gladys Ann

Gonzalez, Catherine Anne H.

Noscal, Eugenio jr. B

Reyes, Karla Jane D

.

Sison, Hannah Louella

Trinidad, Paul Andre P.

Turallo, Jonathan D.

I. II. III. IV. V. VI. VII.

Introduction Patients Profile Patients History Nursing Assessment Anatomy and Physiology Pathophysiology Medical Management a. Laboratory and Diagnostic Test b. Drug Study VIII. Surgical Management

IX. Nursing Care Plan a. Ineffective airway clearance b. Pain c. Anxiety d. Anticipatory Grieving

A. Definition Stillbirth is the birth of a baby who is born without any signs of life at or after 24 weeks pregnancy. The baby may have died during pregnancy (called intrauterine death), labor or birth. WHO defines stillbirth with a birth weight of at least 1000g or a gestational age of at least 28 weeks (third-trimester stillbirth).

B. Causes Maternal Factors: 1. Women who suffer from pre eclampsia also increase the risk of placental abruption by 50%. Women who have experienced a stillbirth in a previous pregnancy should receive careful, regular prenatal care to ensure another stillbirth does not occur.

2. Risk factors for stillbirth that can be identified before a woman becomes pregnant, having a prior stillborn baby, having prior miscarriages and not having other children were all associated with added risk.

3. Women with diabetes had 2.5 times the risk of stillbirth and women aged 40 and older had 2.4 times the risk of stillbirth as women aged 20 to 34.

4. Having an AB blood type, smoking in the three months before pregnancy, overweight/obesity and a history of drug addiction were also associated with higher risks.

One of the common reasons for stillbirths is placental abruption. This is when the placenta begins to strip away from the uterine wall, causing heavy bleeding and deprivation of oxygen to the fetus. Chromosomal abnormalities are another cause of stillbirths. While they are the most common factor for miscarriages in the first trimester, a miscarriage due to a chromosomal abnormality can occur at any time during a pregnancy.

Other causes of stillbirth include gestational growth problems, environmental factors, genetic defects, and bacterial infections (such as listeriosis) in the mother. Additionally, the risk of a stillbirth increases with the maternal age.

C. Signs and SymptomsIf you are pregnant, it is important that you be able to recognize the signs of a possible stillbirth. By catching the symptoms early on, it may be possible to prevent a stillbirth from occurring. Warning signs include: Lack of movement from your baby Significant decrease in baby's movement Vaginal bleeding

Patients Profile:Address: Age: Civil Status:

M. A.C.Silang, Cavite 32 yrs. Old Married

Religion:Occupation:

CatholicHousewife

Admission Date:Time: Attending Physician:

February 14, 20122:13 pm Dr. R.G.

Admitting Diagnosis: Pregnancy Uterine, Pre Gestational Diabetes Mellitus, Chronic Hypertensive Vascular Disease with Super Imposed Eclampsia

Room Number:Hospital:

201-AJonelta OB ward

Date of Discharge: February, 19, 2012

Final Diagnosis: G5P4 (0410) Pre Uterine Delivery, Pre-term, Breech, Stillbirth, baby girl 800gms, Fetal Congenital Anomaly, Pre Gestational Diabetes Mellitus, Chronic Hypertensive Vascular Disease with a Super Imposed Eclampsia

Poor OB history, (Pre-term, stillbirth, neonatal death) Caesarian Section, Hysterectomy under spinal Anesthesia

I. CHIEF COMPLAINT Elevated blood pressure 200/100 mmHg Vital Signs: BP: 200/100 PR: 89 bpm RR: 18 cpm T: 36 CFHT 140 Left lower quadrant

II. HISTORY OF PRESENT ILLNESS: Patient came in OPD Jonelta OB clinic for her scheduled regular prenatal checkup. Asymptomatic, no headache, no blurring of vision, no vaginal bleeding, no hypogastric pain, with good fetal movement. Upon physical examination BP revealed 200/100 mmHg, patient was advised for admission.

III. Past Medical History (-) DM (-) HPN (-) Asthma (+) HospitalizationIV. Family History (+) HPN Father (+) Cancer (breast) Mother (-) DM (-) PTB

V. PERSONAL AND SOCIAL HISTORY: Non- alcoholic beverage drinker Non- cigarette smokerVI. MENSTRUAL/ SEXUAL HISTORY Age of menarche: 11 y/o Menstrual flow regular, consuming 2 pads per day, moderately soaked, lasting for 3 days, uses feminine wash (Betadine) 1st coitus 26y/o One sexual partner

VII. Immunization History Immunization- complete Tetanus Toxoid- complete VIII. Contraceptive History Uses pills from 2009-2011 Stopped due to desired pregnancy

IX. OBSTETRICAL HISTORY G5T0P4A1L 0

X. PAST PREGNANCIESPregnancy Pregnancy Year Gestation Sex Method Where Order Outcome Completed of DeliveryG1 G2 G3 G4 G5 Stillbirth Spontaneous Abortion Stillbirth Stillbirth Present Pregnancy 2006 2007 2008 2009 Preterm 2 Months Preterm Preterm M M F NSVD No curettage NSVD LTCS Hospital Hospital Home

XI. PRESENT PREGNANCY: LMP: July 16, 2011 EDC: April 23, 2012 AOG: 27 1/7 weeksXII. PRENATAL HISTORY: 7 to 12 weeks AOG Ferrous Sulfate and multivitamins given. 13 weeks AOG Diagnosed with UTI, antibiotic was given, name of medication unrecalled, taken for 7 days.

14 weeks diagnosed with GDM, CHVD Medical management - CBG monitoring Diet modification Possible insulin therapy Aspirin once daily was started 16 weeks diagnosed with Bacterial Vaginosis and Cervicovaginitis Given Metronidazole 500mg/ tab BID x7days Albothyl vaginal suppository every other night for 7 doses

18 to 19 weeks Quickening noted. 21 to 22 weeks Ultrasound revealed single, live, intrauterine pregnancy.

PHYSICAL EXAMINATION ( CEPHALO-CAUDAL APPROACH)

VITAL SIGNS: Temperature: 36.5C Blood Pressure: 170/100 mmHg Pulse Rate: 89 bpm Respiratory Rate: 18 cpm

FEMALE INTERNAL STRUCTURE

FEMALE EXTERNAL STRUCTURE

Fetal DevelopmentA. B.

D.

C.

E.

F.

H.

G.

I.

PATHOPHYSIOLOGYModifiable Factors Hypertension (uncontrolled) Presence of UTI Non-Modifiable Factors GDM (controlled) CHVD Poor Obstetric History (Preterm, Stillbirth, Neonatal death)

Vasoconstriction of uterine blood vessels caused by hypertension

Increased maternal and fetal glucose levels caused by gestational diabetes mellitus

Compromised maternal fetal gas exchange

Excess energy expenditure associated with conversion of excess glucose to fat Depletion of fetal oxygen levels Fetal Hypoxia Intrauterine Growth Retardation

Inadequate oxygen supply to fetus

Increased fetal heart rate Release of meconium into amniotic fluid

Respiratory Distress of Fetus

Decrease in fetal movements

Absence of fetal heart tone

Fetal Death

Absence of fetal movements

STILLBIRTH

I. Medical Management 1. Diet a. NPO - This was indicated for decreasing the workload of the stomach. It is a preparatory procedure for the operation.

b. Low salt, Low fat Diet A diet prescribed in the treatment of type 2 diabetes mellitus. It usually contains limited amounts of simple sugars or readily digestible carbohydrates and amounts of proteins, complex carbohydrates, fiber, and unsaturated fats similar to those recommended for the general public.

Dietary regulation depends on the severity of the disease and on the type and extent of insulin therapy. The diet should be designed to prevent wide fluctuation in the amount of glucose in the blood, to preserve pancreatic function, and to prevent chronic diabetic complications.

2. Intravenous Fluids a. D5 NSS to normalize the sugar and body fluids. 3. Foley Catheter a. Indwelling Foley Catheter used to maintain a continuous out flow of urine for patients undergoing surgical procedures that cause a delay in bladder sensation.

4. Monitor Fetal Heart Tone and Uterine Contractions q 15mins and q 4hours. 5. Monitor Vital Signs and Urine Output q 1hour. 6. CBG Monitoring q4hours.7. Insulin Regimen For CBG > 200mg/dL Give 4 units of Humulin R SQ

8. Laboratory Tests CBC with Platelet Count Urinalysis CT (Clotting Time) BT (Bleeding Time) PT test (Prothrombine Time) PTT test (Partial Thromboplastin)

BUN (Blood Urea Nitrogen) and Creatinine test SGPT (Serum Glutamic- Pyruvic transaminase SGOT (Serum Glutamic- Oxaloacetic Transaminase) LDH (Lactate Dehydrogenase) BUA (Blood Uric Acid) HGT (Hemo Glucose Test) CBG (Capillary Blood Glucose)

9. Diagnostic Test a. Pelvic Ultrasound (Sonography) 10. Medications Pre-operative Medications 1. ANTI-HYPERTENSIVE DRUGS Hydralazine 5mg IV PRN for BP > 140/100mmHg Methyldopa 500mg 1 tab q 8hours

2. ANTI INFLAMMATORY DRUG Dexamethazone 12 mg IM q 12hours 3. ANTI INFECTIVE/ ANTIBIOTIC DRUGS Cefuroxime 500 mg tab, 1 tab BID 4. ANTI CONVULSANT DRUG Magnesium Sulfate loading dose 4 grams SIVP 5 grams deep IM on each buttocks 5. ANALGESICS Nubain 5mg + Phenergan 25mg IM 6. ANTI HISTAMINES Promethazine HCL 25mg IM q4 or PRN 7. PRENATAL MULTIVITAMINS

Post Operative Medications 1. ANALGESICS Ketorolac 30mg TIV q8hours x 3 doses (-)ANST Tramadol 50mg q6 x 4doses refer if BP < 90/60mmHg 2. ANTI ULCER DRUG Ranitidine 50mg TIV q8hours x 3 doses while on NPO (1st dose given)

3. ANTI - INFECTIVE/ ANTIBIOTIC DRUGS Ampicillin 500mg q6hours ( ) ANST 4. ANTI HYPERTENSIVE DRUGS Hydralazine 5mg IV PRN for BP > 140/100mmHg

11. Cesarean Section Choice of cesarean section is indicated for stillbirth (fetus died in the uterus), the mother may not have contractions and undergo childbirth. The incision is made horizontally across the lower end of the uterus (called a low transverse incision) preferred for less bleeding and stronger healing. Surgery done due to cases of Gestational Diabetes Mellitus, hypertension and bacterial infection.

II. Surgical Management Pre-operative Informed Consent (Operative Permit/Surgical Consent) Physical Preparations Deep breathing exercise diaphragmatic Preparing the skin - Have full bath to reduce microorganism in the skin.

Preparing the G.I Tract - NPO, cleansing enema as required. Preparing for Anesthesia - Avoid alcohol and cigarette smoking for at least 24 hours before surgery. Promoting rest and sleep - Administer sedatives as ordered.

Psychosocial Preparations Fear of anesthesia Fear of pain Fear of death Fear of disturbance and body image Worries for the outcome of the surgery. Explore clients feelings. Allow clients to speak openly about fears/concerns. Give accurate information regarding surgery.

Intra-operative Positions During Surgery Side Lying for induction of spinal anesthesia. Supine for abdominal surgery. Spinal Anesthesia

Hysterotomy (uterotomy) is any procedure that involves making a cut into a females uterus. This uterine incision may be essential in a number of medical procedures, including Caesarian section. -Hysterotomy by a Cesarean Section was done due to Bacterial Vaginosis and Cervicovaginitis. The uterus accessed through the abdominal muscles. Surgical cuts are made on the lower portion of the uterus.

Post-operative Vital Signs Examine operative site and check dressing. Daily wound care Apply Abdominal Binder

Perineal Hygiene Flat on bed without pillow x 8hours Encourage walking exercise NPO Watch out for signs and symptoms of respiratory distress hypertension, tachycardia, etc.

Keep uterus well contracted at all time. For adequate blood glucose (CBG) and BP control Keep patient warm and comfortableIII. COLLABORATIVE MANAGEMENT Referral to Internal Medicine CBG Monitoring(Pre op Intra op Post op) Hook to Oxygen via Oxygen Mask Hook to Cardiac Monitor And Pulse Oximeter

URINALYSIS RESULT

A urinalysis is a chemical screening of urine for medical purposes. This is a common method for diagnosing any number of medical problems. Doctors will test urine for signs of infection, drug use, red blood cells, protein, glucose and many other medical disorders.

RESULT

NORMAL VALUES

INTERPRETATION

Color

Dark yellow

Pale yellow to amber

Normal

Transparency

Hazy

Clear to slightly Hazy

Presence of bacteria in urine

Reaction(ph)

Acidic 6.0

4.5-8.0

Normal

Protein

++++

Negative

Indication of infection,

diabetes, hypertension

RESULT

NORMAL VALUES

INTERPRETATION

Glucose

NONE

Negative

--

Ketones

NONE

Negative

--

Specific gravity

1.010

1.015-1.025

--

Diacetic Acid

--

RESULT

NORMAL VALUES

INTERPRETATION

Urobilinogen

NONE

0.1-1.0

--

Blood

NONE

Negative

--

Pus cells

10-15/HPF

5-10/HPF

Presence of infection

RBC

1-3/HPF

0-5/HPF

NORMAL

RESULT

NORMAL

INTERPRETATION

VALUES

Epithelial cells

NONE

Few

Crystals

a. A. Uratesb. A. Phosphates

Moderate

--

Mucus threads

--

Bacteria

Moderate

--

Casts

HGT RESULT

Hemo Glucose Test allows a person to know their blood glucose level at any time and helps prevent the immediate and potentially serious consequences of very high or very low blood glucose. Monitoring also enables tighter blood glucose control, which decreases the long-term risks of diabetic complications

RESULT78mg/dl

NORMAL VALUE INTERPRETATION74-106mg/dl NORMAL

COMPLETE BLOOD COUNT (CBC) The complete blood count (CBC) screening test has many applications, and it can help identify a wide variety of diseases. It is used to measure red blood cell and white blood cell count, total amount of hemoglobin in the blood, hematocrit (the amount of blood composed of red blood cells) and mean corpuscular volume (the size of red blood cells). Results can help detect problems such as dehydration or loss of blood, abnormalities in blood cell production and life span, as well as acute or chronic infection, allergies, and problems with clotting.

RESULT

NORMAL

INTERPRETATION

VALUES

Hemoglobin

161

120-170 gm/L

NORMAL

Hematocrit

.48

.37-.47

NORMAL

RBC count

5.76

4-5.5 X10^12/l

Destruction of blood

vesselsWBC count 13.4 X10^9/l Presence of infection

RESULT

NORMAL VALUES

INTERPRETATION

Segmenters

0.67

0.50-0.70

NORMAL

Lymphocytes

0.33

0.20-0.40

NORMAL

Monocytes

NONE

0-0.05

--

Eosinophile

NONE

0-0.04

--

RESULT

NORMAL VALUES

INTERPRETATIO N

Basophile

NONE

0-0.01

--

Stabs

NONE

0-0.04

--

MCV

84.8

80-98 Fl

NORMAL

MCH

28.0

26-32 Pg

NORMAL

RESULT

NORMAL VALUES

INTERPRETATION

MCHC Bleeding time Erythrocyte sedimentation rate(ESR)

330 3 NONE

320-360 g/L 1-5 Min 0-20 Mm/hr

NORMAL NORMAL --

Reticulocyte count Clotting time Remarks: 6

0.5-1.5 % 2-6 Min

-NORMAL --

CLINICAL CHEMISTRY RESULT Clinical Chemistry is defined as the study of substance in biological fluids most specially blood, the methods and principles of determination the intrinsic and extrinsic precautions, the normal levels and he significance of the abnormal values.

RESULT

NORMAL VALUES

CONVENTIONAL REFERENCE VALUES

INTERPRETA TION

ALT

28.00U/L

10-40

28.00IU/L

10-40

--

AST

33.00U/L

10-42

33.00IU/L

10-42

--

BUN

4.03mmol/L

2.5-6.4

11.29mh/dL

7-18

--

RESULT

NORMAL VALUES

CONVENTIONAL REFERENCE VALUES

INTERPRETA TION

CREATININE

60.08umol/L

37-96

0.68mg/dL

0.42-1.09

NORMAL

LACTOSE DEHYDROGENASE

878.00U/L

266-500

878.00IU/L

266-500

Indicates Hypertension

URIC ACID

425.94umol/L

155-428

7.16mg/dL

2.6-7.2

NORMAL

PROTHROMBINE TIME CONTROL TEST

RESULT9.4 seconds

NORMAL VALUE10.5-13.4 seconds

INTERPRETATION--

PARTIAL THROMBOPLASTIN TIME

RESULT

NORMAL VALUE

INTERPRETATION

27.2 seconds

25.4-38.4 seconds

NORMAL

SECOND AND THIRD TRIMESTER ULTRASOUND REPORT Obstetrical ultrasound is also known as prenatal, pregnancy or fetal ultrasound. It keeps track of the growth and development of an unborn baby in the womb. The procedure is often a standard part of prenatal care, as it yields a variety of information regarding the health of the mother and of the fetus, as well as regarding the progress of pregnancy.

Name: M.A.C. Age: 32 years old Referring Physician: M. D. A. Date Requested: February 14, 2012 Examination Done: Early Obstetrical ultrasound GENERAL SURVEYNumber of fetuses Singleton

PresentationFHB Amniotic fluid index

Breech129bpm 14.13cm

Placenta: LocationGrade Distance to internal OS

PosteriorII High

BIOMENTRYBiparietal diameterHead circumference Abdominal circumference Femoral length Average ultrasonic age Ultrasonic EDC Estimated fetal weight

6.25cm 25 wks 2days23.08cm 25 wks1day 20.82cm 25wks 3days 4.34cm 24wks 2days 25wks 5/29/2012 751gms

Fetal Anatomic SurveyLateral vent(