Nursing Case Study for Maternal Newborn
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Outline
Luisa, 25 years old, is a 37-week pregnant patient who presents to triage with abdominal and back pain. She says she thinks she is in labor because her contractions are regular and about 10 minutes apart. Her electronic health record indicates she is G3 P1 A1 and she is followed by a local obstetrics and gynecology office. She states she thinks she may be in labor but “has not seen any fluid.”
What does G3P1A1 mean in regard to this patient?
- Gravida 3 (number of pregnancies), P 1 (number of live or stillbirths) A 1 (number of abortions [induced] or fetal demises before 20 weeks’ gestation). So, Luisa could have 3 pregnancies and no live children (due to stillbirth) or 1 live child. She may have had an abortion or a miscarriage. Note: if A is 0 it may be omitted.
What does the triage nurse understand labor to be in a pregnant woman?
- Labor is defined as regular and painful uterine contractions that cause progressive dilation and effacement of the cervix. Normal labor results in descent and eventual expulsion of the fetus.
Interpreting labor progress depends on the stage and phase: - First stage: The time from onset of labor (i.e., when contractions started to occur regularly every three to five minutes for more than an hour) to complete cervical dilation (noted when first identified on physical examination)
- Phases: The first stage consists of a latent phase and an active phase. The latent phase is characterized by gradual cervical change, and the active phase is characterized by more rapid cervical change.
- Second stage: The time from complete cervical dilation to fetal expulsion.
- Third stage: The time between fetal expulsion and placental expulsion.
- Lack of fluid indicates that the rupture of the membranes (amniotic sac) has not occurred yet
Vital signs are as follows:
BP 150/94 mmHg SpO2 98% on room air
HR 91 bpm and regular Pain 2/10 at rest, 8/10 when she reports a contraction
RR 12 bpm at rest, 24 bpm when she reports what she thinks is a contraction
Temp 36.8°C
Which vital sign is most concerning to the nurse? What should they do regarding this vital sign?
- This blood pressure may indicate pre-eclampsia (“Preeclampsia refers to the new onset of hypertension and proteinuria or the new onset of hypertension and significant end-organ dysfunction with or without proteinuria after 20 weeks of gestation or postpartum in a previously normotensive woman”).
- (Hypertension denotes a rise in systolic blood pressure of 30 mmHg or more and a rise in diastolic blood pressure of 15 mmHg or more from baseline)
- The end-organ dysfunction is evaluated by looking at certain criteria: proteinuria, platelet count, serum creatinine, liver transaminases, pulmonary edema, new-onset and persistent headache unresponsive to analgesics, visual symptoms.”
The nurse decides to take the patient’s blood pressure manually which gives a reading of 130/82. Therefore, the patient is admitted to the labor and delivery unit.
SBAR report is given and Luisa’s admission for labor is started. She is placed in a convertible birthing bed with a fetal monitor attached to her abdomen.
What is the monitor called? What is it for?
- “Tocodynamometry provides contraction frequency and approximate duration of labor contractions” and measures both fetal heart rate and maternal contractions. It is placed externally to watch both mother and baby as labor progresses.” There are also internal devices that can be placed on the fetus within the mother to monitor fetal heart rate.
Luisa progresses through an uneventful labor with her significant other at the bedside. She does not want any pain control and eventually delivers her newborn son, to be named after his father, Santiago.
At the time of birth, how would staff evaluate Santiago?
- “Staff asks three questions. The answers are used to determine whether the newborn is admitted to the normal nursery (neonatal level of care 1) or requires a higher level of care (neonatal level of care 2, 3, or 4)
- Is the newborn’s GA ≥35 weeks?
- Does the newborn have good muscle tone?
- Is the newborn breathing or crying?”
They determine Santiago is healthy enough to be placed on his mother’s chest to promote bonding and encourage breastfeeding. The staff takes him from his mother after a few minutes and she asks why.
What are staff doing when they remove Santiago at 5 minutes old?
- Checking an Apgar score (“Apgar score — The Apgar scores at one and five minutes of age provide an accepted, universally used method to assess the status of the newborn infant immediately after birth. Although data from a population-based study reported that lower Apgar scores of 7, 8, and 9 versus 10 were associated with higher neonatal mortality and morbidity, the Apgar score should not be used to predict individual neonatal outcomes as it is not an accurate prognostic tool
The following signs are given values of 0, 1, or 2, and added to compute the Apgar score. Scores may be determined using the Apgar score calculator. - Heart rate
- Respiratory effort
- Muscle tone
- Reflex irritability
- Color
- Approximately 90 percent of neonates have Apgar scores of 7 to 10 and generally require no further intervention. These neonates usually have all of the following characteristics and can be admitted to the level 1 newborn nursery for routine care:
- Gestational age (GA) ≥35 weeks
- Spontaneous breathing or crying
- Good muscle tone
- Pink color
- Also, they record length, weight, head and chest circumference.
Santiago weighs 3550 grams and is 50.6 cm long. Luisa and Santiago, Sr. ask what that is in pounds and inches so they can tell family and post on social media.
How does the staff respond to this?
- A size chart may be available for staff to convert from metric to English measure and electronic health records may convert these values. But it is key that nursing staff knows how to convert mathematically.
- 50.6 cm/2.54cm per in = 19.9 inches (long)
- 3550 gm x .0022 gm/lb = 7.8 lbs or 7 lbs 12.8 oz. Alternatively, the nurse can convert gm to kg (3550 gm = 3.55 kg) then 3.55 kg x 2.2 lb/kg = 7.8 lbs (the 10th place is multiplied by 16 oz to convert to ounces i.e., 0.8 x 16 = 12.8)
Luisa and Santiago (referred to as a “mother-baby couplet”) are moved from the labor & delivery unit to the postpartum care unit as per protocol. The staff takes the newborn to the nursery for an evaluation. Luisa wants to know what they are looking for and if her son is healthy.
How should the nurse respond?
- Staff frequently (per protocol) assess a postpartum mother for possible complications. A good acronym for this assessment is BUBBLE which is essentially a focused head-to-toe (working from top to bottom) assessment.
- B – breasts (tenderness, size, shape, etc.)
U – uterus (is it firm, boggy? This is done by feeling the fundus and massaging if necessary. This is to help assess for a serious postpartum complication – maternal hemorrhage)
B – bladder (is mom voiding? Is there distension or difficulty urinating? This is also a good time to discuss self-peri-care)
B – bowel (is mom constipated? She may need a stool softener to ease discomfort)
L – lochia (quality, quantity of postpartum bleeding).
You could also add an “L” for legs to check for swelling, Homan’s sign, etc.
E – episiotomy (if this was done, it should be assessed for bleeding or hematoma. Use the REEDA acronym to remember what to look for {Redness, edema, ecchymosis, discharge, approximation)
While the infant is being evaluated in the nursery, postpartum staff come in and assess Luisa. She wants to know why they keep feeling her abdomen and asking her about bleeding. She says, “I thought everything went OK. Why are you always checking on me?”
What is the best answer for Luisa?
- “By pressing on your abdomen, we are assessing your fundus to ensure that the uterine muscle is properly contracting, which prevents bleeding. Similarly, we are evaluating how much you are bleeding to verify that there are no complications after delivering your baby.”
The mother-baby couplet is set to be discharged home after a few days. It turns out that Luisa has no living children as her first pregnancy ended in stillbirth and her second was a miscarriage. She holds Santiago and is tearful as staff prepares to educate her for going home. She says, “I am so afraid I will hurt him or not do stuff right. Why do I keep crying? This is overwhelming.”
Should the nurse address this? What may help the transition from a postpartum unit to home?
- Explain that hormonal changes (for mother) are to be expected at this time but reassure her that discharge criteria have been met. Maybe explain, “In the United States, because of concerns that early discharge could adversely affect maternal and infant health outcomes, both state and federal governments passed postpartum discharge laws in the late 1990s (Newborns’ and Mothers’ Health Protection Act [NMHPA]) to prevent extremely short hospital stays. In general, these laws require insurance plans to cover postpartum stays of up to 48 hours for infants born by vaginal deliveries (96 for c-sections). The impact of legislation ensuring insurance coverage for a minimum of 48 hours has increased the LOHS of newborn infants and their mothers and appears to have decreased neonatal readmission rates and emergency department visits.”
Also, providing resources for education and follow-up will help ease anxiety. Always be prepared with whatever resources the facility and/or OB/GYN practice provides. There may be support numbers or websites available and those should be provided to the mother as appropriate.
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Transcript
Hi everyone. My name is Abby. We’re going to go through a case study together about maternal newborn. Let’s get started. In this scenario, our patient is Luisa. She’s 25 years old and 37 weeks pregnant. She presents to triage with abdominal and back pain. She says she thinks she’s in labor because her contractions are regular and about 10 minutes apart. Her electronic health record indicates that she is G3 P1 A1 and she is followed by a local obstetrics and gynecology office. She states she thinks she may be in labor, but has not seen any fluid. Let’s take a quick recap of what these numbers and letters mean. You may remember from a unit about maternal newborn, there is an acronym “GTPAL.” The G is Gravida that indicates the number of times a patient has been pregnant. T is for term deliveries and those births that are carried to term. P is preterm deliveries. A is abortions or miscarriages, and L refers to the number of live births. Now that you have this reminder, let’s take a look at our critical thinking checks below. They are number one and number two.
Great job. Let’s take a look at her vital signs. Her blood pressure came in just a little elevated at 150/94mmHg, her heart rate is 91 beats per minute with a regular rhythm and her respiratory rate of 12 when she’s at rest and 24 when she reports she’s having a contraction. Temperature looks good at 36.8 degrees Celsius and she’s saturating well on room air at 98%. In regards to pain, she reports she’s a 2 out of 10 when at rest, but of course that increases during a contraction to being more of an 8 out of 10. Now that we have some more information, let’s go ahead and take a look at our critical thinking check number three down below.
Well done. The nurse decides to take the patient’s blood pressure manually, which now gives us a new reading of 130/82 mmHg. Therefore, the patient is admitted to the labor and delivery unit. After an SBAR report, Luisa’s admission for labor is started. She’s placed into a convertible birthing bed and has a fetal monitor attached to her abdomen. Now that we have all this information, let’s take a look at our critical thinking check number four.
Great work. Luisa progresses through an uneventful labor with her significant other at the bedside. She doesn’t want any pain control and eventually delivers a newborn son to be named after his father, Santiago. Let’s take a look at critical thinking check number five and go through the rest of our scenario.
Well done. They determine that Santiago is healthy enough to be placed on his mother’s chest to promote bonding and encourage breastfeeding. We call this skin to skin. The staff takes him from his mother after a few minutes and she asks why. Now, what do you think? Why would they do that? Let’s take a look at critical thinking check number six below and see what we find out.
Wonderful. Santiago weighs 3,550 grams. He also is coming in at 50.6 centimeters long. Luisa and Santiago senior asks what that is in pounds and inches. They want to be able to post on social media for their friends and family. For reference, Santiago was 7.83 pounds and 19.2 inches. Now that we have that information, let’s go ahead and take a look at our critical thinking check below, starting with number seven.
Luisa and Santiago (referred to as a “mother-baby couplet”) are moved from the labor delivery unit to the postpartum care unit. As per protocol. The staff takes the newborn to the nursery for an evaluation. Luisa wants to know what they’re looking for and if her son is healthy. Have you been there yet in clinicals? Let’s take a look at our critical thinking check number eight and see what we find.
Wonderful job. While the infant is being evaluated in the nursery, postpartum staff come in and assess Luisa. She wants to know why they keep feeling her abdomen and asking her about bleeding? She says, “I thought everything went okay. Why do you keep checking on me?” Those nurses? We know why they’re checking on her. Let’s take a look at our critical thinking check number nine.
Wonderful work. The mother-baby couplet is set to discharge home after just a few days. Now let’s take a look back at our GTPAL values. Luisa has no living children as her first pregnancy ended in a stillbirth and her second was a miscarriage. So, as stated in our scenario, she’s a Gravida of G3 P1 A1, so she’s been pregnant three times. She had one preterm delivery and has had one abortion or miscarriage. Her Gravida will change. Now that she’s had Santiago, she gets tearful and she looks at him and says, “I’m so afraid I will hurt him and not do stuff right. Why do I keep crying? This is overwhelming.” The staff continue with some education and she’s excited to go home. Now we can take a look at our critical thinking check number 10 below.
Fantastic job everyone. This wraps up our case study on maternal newborn. Please take a look at the attached study tools and test your knowledge with a practice quiz. We love you guys, now go out and be your best self today, and as always, happy nursing!
References:
from uptodate: Overview of the postpartum period: Normal physiology and routine maternal care
Author:Pamela Berens, MD updated Nov, 2021; Preeclampsia: Clinical features and diagnosis
Authors:Phyllis August, MD, MPHBaha M Sibai, MD, updated Dec, 2021; Labor: Overview of normal and abnormal progression
Authors:Robert M Ehsanipoor, MDAndrew J Satin, MD, FACOG, updated Oct, 2021; Assessment of the newborn infant
Author:Tiffany M McKee-Garrett, MD, updated Oct, 2021; Overview of the routine management of the healthy newborn infant
Author:Tiffany M McKee-Garrett, MD, updated Feb, 2021. Also, some information for this case study was gained from informal interviews with several nurses with experience in labor & delivery and/or postpartum units. When asked about FAQs, they provided some of the questions contained within this case study.
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