Question?

  1. Hello,

    I am a senior nursing student in a diploma program in Cincinnati, OH. We have a scholarly paper in OB and I am stuck on two things. We have to list 5 priority nursing interventions and expected outcomes for a scenario. We have 10 scenario's and I have most of them but these two are throwing me. My question to you all is what do you think is going on with this patient? I will give you the two scenario's and tell you what I think, and if you feel like helping me out throw your two cents in. Thanks in advance.

    Scenario #1: G1 P0 at 32 weeks is admitted to L/D with absence of FHT's and fetal movement. (no more info)
    Could this be a Hydatidiform mole pregnancy or uterine rupture. Am I way off base? Would you want to get the baby out ASAP?

    Scenario #2: You are taking care of a woman in the active phase of labor when her membranes rupture. The amniotic fluid is thick and green. (no more info)
    Is this baby's meconium in the womb? Do you flush mom out before delivery? Should you have respiratory therapy be ready for suctioning and O2 on this infant? Is this something a nurse can do like a NICU nurse? This is a life threatening event for the baby, right?

    Thanks so much for your time,
    Melissa (Goldenearring1)
    RN2B2003@msn.com
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  2. 9 Comments

  3. by   sunnygirl272
    i am not an ob nurse...but here is as far as i will go....
    if you have ideas of what you thinkis going on with these babies, but are not sure, ...try using an internet search engine, ie yahoo, google, etc...and search the terms and diagnoses...
  4. by   Buggs
    Sc#1:if there is no FH and no mvmt at 32wks, wouldn't you wonder if there was a fetal demise in utero-the docs would do an ultrasound to confirm right away. If it was a H.mole don't you think it would have been diagnosed before now?
    Sc#2:whenyou see mec in the fluid, there is the risk that the baby will aspirate it at delivery. Few OB docs will do an amnio infusion to "rinse it out" as there are also risks with the procedure. You should be able to find in your nusing books what you should do when there is mec in the fluid--what should be done at delivery.
  5. by   mother/babyRN
    32 weeks with no fh...Most likely not...Have to decide whether or not she has had prenatal care, or ever felt fetal movement. In either of those two cases, you know or imagine there was most likely a fetal heart at some point. Also need to do leopolds maneuvers and the doc will want to do an ultrasound...Many questions to ask of the pt and whoever (if someone did) accompany here...Did she bleed? If she ever did feel movement, did she notice when it stopped? Make sure the monitor is working and check your results with a fetone > Have another nurse double check....
    If you think there might be a ruptured uterus, other vs changes in the pt and possible bleeding ( although not always obvious) will be apparent if not immediately, then soon...Most likely an intrauterine fetal demise. Many of those never have reasons ascertained...Some reasons could be placental abruption, infarct, nuchal cord around baby or true knot in the cord....You have to put all these factors together with the personal history of the pt, if known...Find out if she has lately or ever used cocaine....Things like that...An abruption does not always show itself in overt bleeding. Sometimes the bleeding is inside....Check for a firm abdomen, ask the pt if she has cramps...
    As for the other scenario, Note the time of rupture and exact appearance of the mec...Doc might (and should) consider amnioinfusion....If so, have the equipment ready....Going to the OR, or close to delivery? Make sure they have the equipment needed to intubate and visualize the cords, with a meconium aspirator there (and o2 and suction), in case you need to suction mec...That is something you try to do as soon as the baby is out and before the first breath if possible. Always have a delee ready to offer hooked up to suction, for the doc to delee on the perineum......Good luck...
  6. by   cindyln
    I would agree that #1 is possible fetal demise in utero. You would proceed to induce the patient. #2 in meconium and my docs would do an amnio infusion.Peds would be notified. They want to be at those deliveries. The babe will be inspected below the cords for meconium aspiration before the shoulders are delivered also.
  7. by   SmilingBluEyes
    molar pregnancy? unlikely but always possible in absence of any information. that info you gave is sketchy at best. here, our dr would do bedside u/s to see what is going on, expecting a fetal demise and then go from there. yes, getting the baby out would be a priority, but likely he/she is dead already.

    in the next case, this is a clear-cut case of meconium staining ...yes the baby had a mec movement in utero. and i agree w/the above, amnioinfusion would be started and baby and mom monitored closely. pediatrician would be called and asked to be at delivery for assessment and intervention upon birth. we would have full suction and intubation setup in anticipation of mec aspiration syndrome.

    good luck.
  8. by   mother/babyRN
    And we would be WISHING we were home and not on that night!
  9. by   SmilingBluEyes
    so TRUE mother/baby
  10. by   mother/babyRN
    Been there done that and HATE to do it.....Right you are Smiling Blue Eyes!
  11. by   Goldenearring1

    Thanks so much for everyone's response. You all are great educators and I really do appreciate it. Sorry I did not get to post earlier as school is terribly demanding and I am lacking in sleep (I know blah, blah, blah).

    As for scenario #1 I think it is an IUFD and whatever it is caused by ie: trauma, uterine rupture, etc. I think my priority would be to call dr so he can order an ultrasound to be verified by 2 R.N.'s and then either let the mom have control as to when she would like to have an induction (with mom being educated in all of the thing's that could go wrong with that decision) or anticipate induction.

    And scenario #2 I found a great article in my Lippincott Manual of Nursing Care on meconium in utero.

    Thanks to everyone, I think it takes me a prompt to get me thinking the right direction.

    Melissa
    RN2B2003@msn.com

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