2. Reproduction: Prematurity Case Study Kelly Hicks, MSN, RNC-OB

3. Labor and Delivery Background Caroline is a Caucasian, 24-year-old G5P4 at 35 weeks gestation with no prenatal care. She presented to the emergency department contracting 1-2 minutes apart, reporting rupture of membranes 18 hours ago. Upon examination, she was 8 cm and 90% effaced with fetal heart tones of 180 bpm. Fifteen minutes after arrival Baby Benjamin was born via precipitous vaginal delivery at 1859.

4. Questions 1. What are the implications of Caroline’s lack of prenatal care? 2. What risks are involved in a precipitous delivery? 3. What other risk factors are present?

5. Initial Newborn Assessment After delivery, Baby Benjamin was admitted to the newborn nursery around 1915. His Apgar scores were 5 at one minute and 7 at five minutes. At one minute, points were deducted for color, tone, and reflexes. He weighed 4 lbs 9 oz and was 18 ½ inches long. VS: HR 145, RR 80, T 97.0 axillary, O2 sat 89%. Blood glucose 35 mg/dL. Upon assessment, he had nasal flaring, retractions, grunting, and crackles in bilateral lung fields.

6. Questions 4. Based on the assessment data, which of the findings are abnormal and require intervention? 5. What interventions should the nurse take at this time?

7. Initial Interventions At 1930 Baby Benjamin was given an ounce of D5W and blow by O2 at 100%. He was placed under the radiant warmer. Blood and skin cultures were sent to the lab. A portable chest x-ray was performed. At 1945 VS: HR 160, RR 92, T 97.0 axillary. With blow by O2 his O2 sat was 91%, but dropped to 85-87% when taken away.

8. Questions 6. Is Baby Benjamin experiencing transient tachypnea (TTN) or respiratory distress syndrome (RDS)? Give data to support why it is one versus the other. 7. What nursing interventions need to be done next?

9. Further Assessment At 2100, Baby Benjamin has a blood glucose of 42 mg/dL. VS: HR 155, RR 108, T 96.7 axillary O2 sat 90% with blowby O2. The nasal flaring and retractions have not yet subsided. He is left under the radiant warmer and given oxygen therapy via a hood.

10. Questions 8. Discuss indicators of the presence of infection. 9. What put the baby at risk for infection? 10. What frequent assessments should be made at this point?

11. Worsening Status At 2300 Baby Benjamin is pale with circumoral cyanosis. He is difficult to arouse and continues to having nasal flaring, retractions, grunting, and is now “singing”. Orders were received from the pediatrician to start an IV of D51/2 NS at 5 mL/hr and Baby Benjamin was transferred to a neonatal intensive care unit (NICU) 30 miles away.

12. Questions 11. Why did Baby Benjamin require transfer to another hospital? 12. What could be the reason behind Baby Benjamin’s lethargy? 13. Why was he continuing to show signs of respiratory distress?

13. At the NICU At 0100 Baby Benjamin is in the NICU and has been placed on a ventilator and phototherapy for hyperbilirubinemia that caused him to be jaundice.

14. Questions 14. Why was Baby Benjamin placed on a ventilator? 15. What caused Baby Benjamin to become jaundice? 16. What nursing interventions should be done in regards to phototherapy? 17. Develop a clinical care model for this baby including psychosocial needs of the family.

15. Questions with Answers 1. What are the implications of Caroline’s lack of prenatal care? Lack of prenatal care can be a result of substance abuse in the mother that she does not want revealed. The dates could be off and the baby might be younger than 35 weeks. There may be congenital anomalies or issues present that can affect the baby’s transition. Unknown maternal blood type, rubella, hepatitis B HIV and GBS status. Unknown STD status.

16. Questions with Answers 2. What risks are involved in a precipitous delivery? Baby is at risk for bruising, trauma, palsies, and hyperbilirubinemia. Mom is at risk for vaginal tears and PP hemorrhage. 3. What other risk factors are present? ROM for 18 hours-risk for infection, neonatal withdrawal if substance abuse was present. Preterm delivery, unknown GBS status. Fetal tachycardia noted prior to delivery.

17. Questions with Answers 4. Based on the assessment data, which of the findings are abnormal and require intervention? RR too high, T too low, blood glucose too low, O2 sat too low. Nasal flaring, retractions, grunting, and crackles in bilateral lung fields all abnormal. 5. What interventions should the nurse take at this time? Baby needs to be placed in radiant warmer. Blow by O2 administered. Glucose water given. Blood sugar rechecked after feeding. Notify MD to receive orders for chest x-ray.

18. Questions with Answers 6. Is Baby Benjamin experiencing transient tachypnea (TTN) or respiratory distress syndrome (RDS)? Give data to support why it is one versus the other. TTN includes respiratory symptoms with no cause. Respiratory distress syndrome occurs in premature babies with a deficiency in surfactant. Baby Benjamin is premature and a chest x-ray was performed to determine the reason behind the respiratory issues.

19. Questions with Answers 7. What nursing interventions need to be done next? Recheck baby’s blood glucose. Keep baby under warmer, checking temperature every 15 mins. Frequent vital sign assessment and continue to administer blow by O2.

20. Questions with Answers 8. Discuss indicators of the presence of infection. Inability to keep temperature and blood glucose up even with intervention. FHR tachycardia prior to delivery. 9. What put the baby at risk for infection? Prolonged ROM, prematurity, unknown GBS status. 10. What frequent assessments should be made at this point? VS, O2 sats, blood glucose, respiratory assessment.

21. Questions with Answers 11. Why did Baby Benjamin require transfer to another hospital? The hospital may not be equipped to care for such a sick, premature baby. It may not be a level IV and Baby Benjamin may require a ventilator to assist with the respiratory symptoms. 12. What could be the reason behind Baby Benjamin’s lethargy? Continued low blood glucose, possible pathologic jaundice since maternal blood type and Rh factor is unknown. Infection could spread and become sepsis.

22. Questions with Answers 13. Why was he continuing to show signs of respiratory distress? The baby is premature so the lungs may not be mature and there may be a deficiency in surfactant. Infection can be a cause of some of the distress as well.

23. Questions with Answers 14. Why was Baby Benjamin placed on a ventilator? Lack of surfactant results in an inability to breathe on his own. The ventilator assists Baby Benjamin in breathing with less difficulty and without expending so much of his energy just to breathe. 15. What caused Baby Benjamin to become jaundice? Pathologic jaundice may be the case if there is a ABO/Rh incompatibility. The precipitous delivery can also cause trauma that will contribute to hyperbilirubinemia.

24. Questions with Answers 16. What nursing interventions should be done in regards to phototherapy? Initial VS with axillary temperature. VS at least every 4 hours, temperatures at least every 2 hours if not under warmer as well. Eyes and genitals only covered. Repositioning every 2 hours. Only serum bilirubin checks after initiation of phototherapy with blood draws with phototherapy lights off. Monitor I&Os, daily weights.

25. Questions 17. Develop a clinical care model for this baby including psychosocial needs of the family. Nursing Diagnoses that can be included: Ineffective Breathing Pattern Impaired Gas Exchange Ineffective Thermoregulation Altered Nutrition: Less than Body Requirements Ineffective Family Coping: Compromised Altered Parenting

26. References Gregory, D. (2006). Instructor’s manual to accompany clinical decision making case studies in maternity and women’s health. Clifton Park, NY: Thomson Delmar Learning. Ladewig, P., London, M. & Davidson, M. (2010). Contemporary Maternal- Newborn Nursing Care. (7 th ed.) New York: Pearson.