The following is a case simulation involving a patient initially encountered in Labor and Delivery. While the initial encounter occurred in a specific setting, this particular case will evolve and include transitions to various specialty areas over the healthcare continuum.
Encourage open discussion from nurses that represent a variety of specialties.
Promote learning based on the:
details of the case
evaluation of the data
known interventions in order to provide holistic care
Recognize maternal morbidity and mortality as a serious public health issue facing the world.
Introduction
The initial presentation that will proceed is meant to set the tone for the next set of events that will occur. I would like to preface by saying that this particular part of the case is where I have no actual nursing experience so I encourage colleagues who work in this specialty area to chime in with their responses.
Let's keep this lively, but also make sure we are respectful of each other. Remember that we work in different hospitals and protocols may be different. Also, be aware that while the following scenario seems "garden variety", it will get more "exciting" as we move along.
Case Specifics
History / Presentation
EJ is a 32-year old, Gravida 4 Para 2, at 34 weeks and 2 days gestational age. She has no chronic medical problems but admits to current tobacco smoking since age 17. She says that she has been trying to quit and has cut back her smoking to 2-3 cigarettes a day. She lives with her husband and two children ages 3 and 5 in a 2-bedroom apartment.
She receives prenatal care at an urban Federally Qualified Healthcare Center (FQHC). She previously worked as a server at a restaurant but has become unemployed for a couple of months due to restaurant closures from the coronavirus pandemic. She has good family support from her parents and her husband, RJ, who is a delivery truck driver. She is insured through her husband's coverage.
Today, she called her Women's Health Nurse Practitioner (WHNP) when she experienced a gush of watery fluid from her lady parts while playing with her children. She was told to come to OB Triage at the nearby Tertiary Medical Center Antepartum Unit. Upon presentation, she was seen by the OB Triage nurse who found her anxious but well-appearing.
Vital Signs
Temperature: 36.7 degrees C
Heart Rate: 84
Respiratory Rate: 16
Blood Pressure: 112/74
O2 Saturation: 96% RA
Fetal Heart Rate (FHR): 140
Physical / Pelvic Examination
An OB-Gyn resident saw EJ and performed a physical examination that revealed clear, pale yellow, odorless fluid leaking out of her endocervical canal with pooling in the lady partsl vault.
Diagnostic Studies
The OB-Gyn resident performed ultrasonography which revealed:
oligohydramnios
a fetus that is small for its age, without birth defects, in no distress
a placenta that does not cover the cervix
Recommendation
The OB-Gyn team recommended admission to the Antepartum Unit.
Diagnosis
At this point, EJ's diagnosis seems obvious but you are welcome to state it in your response to the thread.
1 - As EJ's nurse, state some assessment findings that would make you concerned.
2 - As the nurse in that unit, what laboratory tests and monitoring procedures would you anticipate in this case, and why?
Specializes in Nurse Leader specializing in Labor & Delivery.
On 9/9/2020 at 5:46 AM, klone said:
The manufacturers never recommend breastfeeding while taking their medications. Just saying. ?
I will cite the studies that looked at propofol continuous infusion when I get to work.
Just realized I forgot all about this. I looked in Hale's and I was mistaken that the propofol study was looking at continuous infusion postpartum. It was during labor only.
I still stand by my opinion that it's not necessary to pump and dump, but I will own that it's my opinion only. And we all know about those...:)
I will also say that in this particular case, the debate is likely academic only, as the likelihood of a critically ill mother who suffered from PPH and DIC being able to produce more than drops in the first several days after delivery is quite slim. Plus, the fact that she is unconscious, likely lying supine, means that pumping is going to be more for the stimulation than actual collection of anything substantive (have you ever tried pumping an unconscious mom who's lying flat on her back? It's pretty impossible to actually collect anything).
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
1 hour ago, klone said:
I will also say that in this particular case, the debate is likely academic only, as the likelihood of a critically ill mother who suffered from PPH and DIC being able to produce more than drops in the first several days after delivery is quite slim. Plus, the fact that she is unconscious, likely lying supine, means that pumping is going to be more for the stimulation than actual collection of anything substantive (have you ever tried pumping an unconscious mom who's lying flat on her back? It's pretty impossible to actually collect anything).
I'm not actually involved in the actual pumping in these critically-ill, intubated, on sedative drips post-partum patients but always assumed that the order itself is just so we continue stimulating lactation so that when they are extubated, they can breastfeed or pump and store. We've had COVID19 mothers who delivered but only a few went into full blown ARDS requiring prolonged mechanical ventilation and needed to be proned. For that matter, I don't know the process for pumping for our completely awake, ICU post partum patients either who only stay for a day after PPH from uterine atony or preeclampsia. I know it's a big deal that we store the breastmilk.
1. 34.2 weeks, SGA, smoker, leaking fluid, oligohydramnios. 2. Check fluid for ferning. Do L&D admit labs, start IV, place on baby monitor; may need to start antibiotics.
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
1 hour ago, walkingrock said:
1. 34.2 weeks, SGA, smoker, leaking fluid, oligohydramnios. 2. Check fluid for ferning. Do L&D admit labs, start IV, place on baby monitor; may need to start antibiotics.
Great! Ferning is test that determines that the fluid is amniotic. You may move to the next step:
You’re right - It used to be thought that entry of fetal cells into maternal circulation is what caused AFE, but now we know that fetal cells are present in maternal circulation a good percentage of the time without untoward effects. It’s believed that in a tiny percentage of women, this causes a sudden anaphylactic reaction. I haven’t heard that there is a big push to rename AFE, however.
Totally not OB here and haven't given a thought to maternal-fetal circulation for several decades. Just wondering, though - do fetal waste products enter maternal circulation and get disposed of by Mom throughout pregnancy?
That's a good thing. And the oligohydramnios is simply because her water broke.
Baby is SGA though which is associated with oligohydramnios. Is it common for ultrasound to measure amniotic fluid as low after water breaks? I guess I would assume the tech would take ROM into account. I was told it depends on where on the sac the water breaks (top of sac means less leaking with ROM, bottom of sac means more leaking)
And it may sound like a menial thing to mention but if it was true oligohydramnios, baby could have GU deformity. (this is my thinking out loud, correct me if I'm wrong)
Specializes in Nurse Leader specializing in Labor & Delivery.
NurseyNurse1005 said:
Baby is SGA though which is associated with oligohydramnios. Is it common for ultrasound to measure amniotic fluid as low after water breaks? I guess I would assume the tech would take ROM into account.
No, we typically do not form a diagnosis of oligo after ROM because it's kind of meaningless. It would be expected that there would be low fluid after ROM. Nevertheless, in this case study, the patient was labeled as oligo after PPROM. The oligo was caused by the ROM, there would be no way to prove otherwise without a baseline AFI/MVP.
Interesting to read this 4 years later - I have learned WAY more about critical care obstetrics AND AFE since I participated in this thread in 2020!
No, we typically do not form a diagnosis of oligo after ROM because it's kind of meaningless. It would be expected that there would be low fluid after ROM. Nevertheless, in this case study, the patient was labeled as oligo after PPROM. The oligo was caused by the ROM, there would be no way to prove otherwise without a baseline AFI/MVP.
Interesting to read this 4 years later - I have learned WAY more about critical care obstetrics AND AFE since I participated in this thread in 2020!
Thank you for the clarification!! And I didn't even know there was such a thing as critical are obstetrics. I'm only in the end of my third semester of nursing school . Do you have any book recommendations on the topic?
klone, MSN, RN
14,857 Posts
Just realized I forgot all about this. I looked in Hale's and I was mistaken that the propofol study was looking at continuous infusion postpartum. It was during labor only.
I still stand by my opinion that it's not necessary to pump and dump, but I will own that it's my opinion only. And we all know about those...:)
I will also say that in this particular case, the debate is likely academic only, as the likelihood of a critically ill mother who suffered from PPH and DIC being able to produce more than drops in the first several days after delivery is quite slim. Plus, the fact that she is unconscious, likely lying supine, means that pumping is going to be more for the stimulation than actual collection of anything substantive (have you ever tried pumping an unconscious mom who's lying flat on her back? It's pretty impossible to actually collect anything).