Uncomplicated labor and delivery - Nursing Case Study

Pathophysiology

• Primary mechanism: Hormonal Triggering - Labor and delivery commence when the mother's body releases oxytocin, a hormone that triggers uterine contractions. These contractions help to dilate the cervix, preparing for the baby's passage through the birth canal.

• Secondary mechanism: Fetal Positioning - The baby’s alignment within the uterus is critical for a successful delivery. Ideally, the baby is positioned head-down, facing the mother's back (anterior position). This position allows the smallest part of the baby's head to lead the way through the cervix and into the birth canal.

• Key complication: Prolonged Labor - If labor does not progress as expected, it is often due to issues with the "Three P's" - Power (strength of contractions), Passage (size and shape of pelvis and birth canal), and Passenger (baby's size, position, or presentation). This can lead to exhaustion, distress for mother and baby, and increased risk of infection or intervention.

Patient Profile

Demographics:

32 years old, Female, Office worker

History:

• Key past medical history: Gestational diabetes during current pregnancy, History of mild hypertension

• Current medications: Insulin, Prenatal vitamins

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Labor pains with irregular contractions

• Key symptoms: Lower back pain, abdominal pain, irregular contractions, decreased fetal movements

• Vital signs: Blood pressure: 150/95 mmHg, Pulse: 110 bpm, Temperature: 37.5°C, Respiratory rate: 22 breaths per minute

Section 1

New Diagnostic Results:

The patient's blood pressure remained elevated at 155/100 mmHg and pulse rate was noted to be consistently high at 115 bpm. Her respiratory rate increased to 24 breaths per minute indicating increased distress. An assessment of the fetal heart rate revealed tachycardia at 170 beats per minute, suggesting possible fetal distress. Her blood glucose level was also elevated at 12.5 mmol/L, indicative of poor glycemic control.

Change in Patient Status:

During a labor examination, the patient's cervix was found to dilated to only 4 cm, despite her being in active labor for over six hours. Her contractions were noted to be irregular and not strong enough to facilitate further dilation. The patient also reported increased lower back pain and the feeling of pressure in her pelvis. On palpation, the fetal position was determined to be occiput posterior (OP), where the baby's head is down but facing the mother's abdomen, which can cause more difficult and painful labor.

These findings suggest a potential diagnosis of gestational hypertension or preeclampsia, poor glycemic control, and possible obstructed labor due to malposition of the fetus. Immediate interventions will be needed to manage the mother's high blood pressure and blood glucose levels, and to address the abnormal fetal position and non-progressing labor.

Section 2

New Complications:

As the labor progressed, the patient became increasingly restless and her blood pressure remained persistently high at 165/105 mmHg. She was also noted to have proteinuria, with 2+ protein on a urine dipstick test. The patient's visual disturbances worsened and she reported seeing flashing lights. The fetal heart rate continued to be elevated at 175 beats per minute. A blood test revealed elevated liver enzymes and low platelet count, indicating possible HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count), a severe form of preeclampsia.

These findings indicate that the patient's condition is deteriorating, potentially escalating from gestational hypertension to severe preeclampsia with signs of HELLP syndrome. The persistently high fetal heart rate and the mother's symptoms point towards an increased risk for both mother and fetus. The medical team will need to consider prompt interventions to manage the mother's blood pressure, proteinuria, and visual disturbances, while also addressing the malposition of the fetus and the non-progressing labor. The patient's elevated liver enzymes and lowered platelet count should also be closely monitored to prevent further complications.

Section 3

Change in Patient Status:

Upon reassessment, the patient's blood pressure spiked to 175/110 mmHg, indicating further deterioration. She complained of severe headache and worsening visual disturbances, with the addition of blurring vision, suggesting probable cerebral edema. The patient also reported upper abdominal pain and nausea, symptoms that are consistent with liver involvement in HELLP syndrome. The fetal heart rate remained elevated at 180 beats per minute with reduced variability, a sign of fetal distress. The patient's cervix was still dilated to 5 cm with no significant change in the last 2 hours, indicating a stalled labor.

This change in patient status highlights a critical juncture in the patient's care and necessitates immediate interventions. The medical team needs to manage the patient's severe hypertension promptly to prevent the risk of cerebral hemorrhage. The worsening visual disturbances and headache could indicate imminent eclampsia, further emphasizing the need for swift action. The elevated fetal heart rate and reduced variability signal potential fetal hypoxia, necessitating fetal monitoring and possible delivery intervention. The stalled labor further complicates the situation, suggesting the possible need for a cesarean delivery to ensure the safety of both mother and baby.

Section 4

New Diagnostic Results:

Further diagnostic tests were conducted to confirm the suspected diagnosis of HELLP syndrome and pre-eclampsia. The lab results showed elevated liver enzymes, with aspartate aminotransferase (AST) at 180 U/L and alanine aminotransferase (ALT) at 220 U/L. The patient's platelet count came back significantly diminished at 90,000/uL, indicating a risk of disseminated intravascular coagulation (DIC). The serum creatinine was elevated at 1.5 mg/dL, suggesting impaired kidney function. The urinalysis revealed 3+ proteinuria, which is consistent with pre-eclampsia. The results of these diagnostic tests confirm the presence of HELLP syndrome and pre-eclampsia.

These lab findings necessitate a modification in the patient's plan of care and demand immediate medical intervention. The elevated liver enzymes and decreased platelet count indicate liver damage and a potential for bleeding complications associated with HELLP syndrome, whereas the elevated creatinine level and proteinuria point towards renal involvement. The medical team needs to manage these complications while also considering the potential for eclampsia given the patient's symptoms and worsening hypertension. The team must also contemplate the best method of delivery given the fetal distress and stalled labor. The clinical reasoning for the next steps should involve careful consideration of these new diagnostic results and their implications on both maternal and fetal health.

Section 5

New Complications:

As the medical team continued to monitor the patient, her blood pressure readings remained persistently elevated, fluctuating between 160/110 mmHg and 170/115 mmHg despite administration of intravenous labetalol. A sudden onset of a severe headache was reported by the patient, accompanied by visual disturbances such as blurred vision and sensitivity to light. This indicated a potential progression to eclampsia, which was further supported by the patient's newly developed hyperreflexia and clonus on physical examination.

Moreover, the fetal heart rate tracing started to exhibit late decelerations, indicating potential fetal hypoxia. The obstetric team performed a sterile vaginal exam, revealing a cervix that remained 3 cm dilated and 50% effaced with the fetus at -2 station, indicating stalled labor. Given these new complications and the lack of progress in labor, the medical team must now consider the need for an emergency cesarean section to ensure the safety of both the mother and the baby. In addition, the team must be prepared for potential complications during surgery due to the patient's low platelet count and risk of bleeding. This requires the collaborative effort of the obstetric, anesthesia, and surgical teams, along with the neonatal intensive care unit for immediate neonatal support post-delivery.