Labor and birth - Nursing Case Study
Pathophysiology
• Primary mechanism: Hormonal shifts - Oxytocin and prostaglandins increase, stimulating uterine contractions. These contractions dilate the cervix, allowing the baby to descend into the birth canal.
• Secondary mechanism: Mechanical forces - As the fetus descends, pressure is exerted on the cervix, further stimulating contractions (Ferguson reflex). This results in full dilatation of the cervix and progress in the stage of labor.
• Key complication: Failure to progress - If contractions are ineffective or the baby cannot pass through the birth canal, labor stalls. This can necessitate medical intervention, such as a C-section, and can increase risk for maternal and fetal distress.
Patient Profile
Demographics:
27-year-old female, software engineer
History:
• Key past medical history: Gestational diabetes during the current pregnancy, obesity
• Current medications: Prenatal vitamins, metformin for gestational diabetes
• Allergies: Penicillin
Current Presentation:
• Chief complaint: Labor contractions with increased frequency and intensity
• Key symptoms: Severe abdominal pain, vaginal bleeding, blurred vision, swelling of hands and face
• Vital signs: Blood pressure 155/95 mmHg, pulse 105 bpm, respiratory rate 20 breaths per minute, temperature 98.6 F.
Section 1
Change in Patient Status:
The patient’s labor was progressing slowly and her blood pressure continued to remain high. Her pain was escalating despite the use of pain management techniques and epidural anesthesia. Additionally, the patient began to complain of a severe headache and visual disturbances. On reassessment, her blood pressure was 165/110 mmHg, pulse 112 bpm and respiratory rate 23 breaths per minute. The obstetrician was notified of the change in patient's status and the development of these new symptoms.
New Complications:
The obstetrician diagnosed the patient with preeclampsia, a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. Left untreated, preeclampsia can lead to serious complications for both mother and baby. The patient's gestational diabetes, obesity, and elevated blood pressure readings had already placed her at a higher risk for this condition. The patient's severe headache and visual disturbances, in conjunction with her high blood pressure, confirmed this diagnosis. The next course of action would be to manage the preeclampsia while continuing to monitor the progression of labor, ensuring the safety of both mother and baby.
Section 2
Change in Patient Status:
Despite the management of preeclampsia, the patient's blood pressure remained elevated at 165/115 mmHg and her pulse accelerated to 120 bpm. She also began to experience sudden, severe pain in the upper right abdomen, along with nausea and vomiting. The patient's urine output decreased significantly, and the urine was dark in color. Upon reassessment, the fetal heart rate was noted to be less than 110 beats per minute, indicating potential fetal distress.
Response to Interventions:
The obstetrician ordered immediate laboratory tests, including liver function tests, complete blood count, and urinalysis to assess the extent of organ damage. Intravenous magnesium sulfate was administered to prevent seizures, a severe complication of preeclampsia. A dose of corticosteroids was also given to help speed up the baby's lung maturity in case an early delivery becomes necessary. The patient was placed on her left side to optimize uteroplacental blood flow and oxygen supply to the baby, and continuous fetal monitoring was initiated. Despite these interventions, the patient's condition continued to deteriorate, and an emergency cesarean section was deemed necessary to ensure the safety of both mother and baby.
Section 3
New Complications:
Despite the swift response to the escalating situation, the patient started showing signs of HELLP syndrome, a severe form of preeclampsia characterized by hemolysis, elevated liver enzymes, and low platelet count. She reported worsening epigastric pain, and her latest blood work showed a decrease in platelet count to 80,000 uL (normal range: 150,000 to 450,000 uL), elevated liver enzymes with AST of 120 U/L and ALT of 150 U/L (normal range for AST and ALT: 10 to 40 U/L), and signs of hemolysis with a rise in LDH to 600 U/L (normal range: 140 to 280 U/L). Her prothrombin time (PT) and partial thromboplastin time (PTT) were also slightly prolonged, indicating a potential coagulopathy.
Response to Interventions:
On observing these alarming signs, the healthcare team immediately notified the obstetrician. The patient was transferred to the Intensive Care Unit (ICU) for closer monitoring and management. The obstetrician ordered a plasma transfusion to manage the patient's coagulopathy and to prepare for the possible need for an emergent cesarean section. The patient was also given a second dose of corticosteroids to further promote the baby's lung maturity in anticipation of premature delivery. Yet, these escalated interventions did not significantly improve the patient's condition, adding to the complexity and urgency of the situation. The healthcare team had to prepare for the potential complications associated with HELLP syndrome, including placental abruption, acute renal failure, and disseminated intravascular coagulation.
Section 4
New Diagnostic Results:
As the patient's condition continued to deteriorate, the obstetrician ordered an ultrasound to assess the health of the baby and the status of the placenta. The ultrasound revealed a small-for-gestational-age fetus with signs of intrauterine growth restriction (IUGR). There was also evidence of placental abruption, further complicating the situation. The patient's urine output had decreased significantly, with only 20 mL/hr over the past three hours, indicating possible onset of acute renal failure. A urine dipstick test showed proteinuria (+++), and the patient's creatinine levels had risen to 1.4 mg/dL (normal range: 0.5 to 1.1 mg/dL), further supporting the suspected renal impairment.
Change in Patient Status:
Despite the plasma transfusion, the patient's platelet count continued to decrease, now at 60,000 uL, and her liver enzymes continued to rise, with AST now at 140 U/L and ALT at 180 U/L. Her LDH levels also continued to increase, now at 700 U/L. The patient complained of worsening epigastric pain, along with new onset of severe headache and blurred vision, signs of cerebral edema, a life-threatening complication of severe preeclampsia and HELLP syndrome. The patient's blood pressure also continued to rise despite antihypertensive therapy, now at 160/110 mmHg. The rapid deterioration in the patient's condition necessitated immediate intervention to prevent further complications and ensure the safety of both the mother and the baby.
Section 5
New Diagnostic Results:
Due to the patient's worsening condition, a non-stress test was ordered to assess fetal well-being. The results showed a non-reassuring fetal heart rate with late decelerations suggesting fetal hypoxia. The fetal heart rate was irregular, averaging between 120-140 bpm with poor variability. A biophysical profile was also performed, which showed a score of 4 out of 10, indicating severe fetal distress. The amniotic fluid index was below normal at 5cm, signifying oligohydramnios. Given the patient's worsening renal function, a renal ultrasound was done which showed signs of bilateral hydronephrosis, a common complication associated with severe preeclampsia and HELLP syndrome.
New Complications:
While preparing for an emergent cesarean section due to the deteriorating fetal status, the patient's condition worsened with a sudden onset of a convulsive seizure, a manifestation of eclampsia. Despite being administered a bolus of magnesium sulfate, the patient's blood pressure continued to soar, now at 170/120 mmHg, putting her at risk of a hypertensive crisis. Her respiratory rate increased to 28 breaths per minute and oxygen saturation dropped to 92% on room air. A repeat platelet count showed a further decrease to 45,000 uL, increasing her risk of disseminated intravascular coagulation and massive hemorrhage during the surgical procedure. The patient remained disoriented post-seizure, displaying signs of altered mental status. These new complications necessitate immediate multidisciplinary action to prevent maternal and fetal morbidity and mortality.