1. PERINATAL UNFOLDING CASE STUDY
Tanya Carmichael, MSN, RNC
Christina Harkins, MSN, RNC
Mary Lou Gies, Ed.D, RN
La Salle University

2. INITIAL PRENATAL VISIT
You are a registered nurse (RN) working in a Women’s Health Clinic. Mary Johnson, 38 years old, presents to the prenatal clinic after missing her last 2 menstrual cycles. Her home pregnancy test was positive. An ultrasound at the clinic confirms pregnancy. Gestational age is calculated to be 10 weeks. An initial assessment of Ms. Johnson’s medical and obstetrical history follows.

3. HISTORY
Obstetric/Gynecologic (OB/GYN) history (hx): Uncomplicated spontaneous vaginal delivery (SVD) at 38.2 weeks (5 years ago); Cesarean section (C/S) x 1 at 37.5 weeks for non- reassuring fetal heart tones (FHT) (3 years ago); abnormal Papanicolaou (PAP) smear x 1, + human papilloma virus (HPV), colposcopy within normal limits (WNL); Chlamydia with treatment (7 years ago)
Medical hx: Chronic hypertension (HTN) x 5 years; asthma  no intubations or hospitalizations; hx of breast biopsy, benign (2 years ago)
Allergies: Penicillin

4. HISTORY
Social hx:
(+) tobacco, “occasional” per patient (pt), <5 per/day currently, has smoked “off and on” for 15 years
(+) cocaine use, states she has not used any cocaine/drugs for > 1 year; (-) alcohol use
Abusive partner with first pregnancy, states she has a new partner x 4 years
Depression, currently not taking meds for treatment (tx)
Medications: Prenatal vitamins; Labetalol 200mg BID; Albuterol inhaler as needed (prn)
Family hx: Insulin-dependent diabetes mellitus (mother); HTN and heart disease (father); lung cancer (CA) (maternal grandmother, deceased)

5. What should the nurse consider related to caring for a patient with a history of domestic abuse, drug use, sexually transmitted diseases and depression?

6. Professional nurses should be aware of attitudes, values and beliefs that they hold related to patients from different social backgrounds so that care is not affected negatively.
QSEN: KSA (next slide)

7. QSEN KSA: PATIENT CENTERED CARE
KNOWLEDGE: Review patient support system and resources
SKILL: Refer patient to appropriate resources r/t domestic abuse and addiction as indicated
ATTITUDE: Recognize personally held attitudes about working with patients from different ethnic, cultural and social backgrounds; willingly support patient- centered care for individuals and groups whose values differ from own

8. INITIAL PRENATAL VISIT
Vital Signs (VS):
Temp F, RR 20, HR 86, BP 142/79
WHAT LABORATORY AND ASSESSMENT DATA SHOULD BE COLLECTED DURING THIS VISIT?
AFTER CONSIDERING THE INFORMATION PROVIDED, WHAT OTHER ASSESSMENTS AND ISSUES NEED TO BE ADDRESSED DURING THIS PRENATAL VISIT?

9. LAB DATA: ASSESSMENT DATA:
WHAT LABORATORY AND ASSESSMENT DATA SHOULD BE COLLECTED DURING THIS VISIT?
LAB DATA:
Complete blood count (CBC)
Blood type and Rh
Rh antibody screen
Gonorrhea and Chlamydia cultures
Serology - Syphilis (RPR or VDRL)
Rubella
Hepatitis B surface antigen
HIV testing (offer test; provide pretest counseling)
Urine drug screen (UDS)
ASSESSMENT DATA:
Baseline VS: pay special attention to BP – pt with hx of HTN
Weight: 150 lbs
FHR (from doptone or ultrasound): 145
Baseline review of systems assessment

10. LABORATORY VALUES What is the significance of these lab values?
Determination
Patient Result
Reference / Normal
Hemoglobin (Hgb)
12.7 g/dL
Female: g/dL
Hematocrit (Hct)
37%
Female: 40%-48%
White Blood Cell Count (WBC)
9,000
,000/mm³
Blood type and Rh A-
N/A
Rh antibody screen + _
Gonorrhea & Chlamydia cultures
Serology (RPR, VDRL)
Rubella
Immune
HIV
UDS
Hepatitis B surface antigen
Reference: Pagana, K.D, & Pagana, T.J. (2003) Diagnostic & Laboratory Test Reference,, 6th Ed. Mosby, Inc.: St. Louis, MO

11. Smoking history: council pt. on smoking cessation.
AFTER CONSIDERING THE INFORMATION PROVIDED, WHAT OTHER ASSESSMENTS AND ISSUES NEED TO BE ADDRESSED DURING THIS PRENATAL VISIT?
Safety Screening: Pt has a history of an abusive partner, depression and drug use. Psychosocial assessment (including domestic violence) and depression / suicide risk would be important during this first visit.
Smoking history: council pt. on smoking cessation.
QSEN KSA: Safety
Skill: Use appropriate strategies, such as Psychosocial Screening Tool (slide 13) and Depression/Suicide Risk Assessment (slide 15):
to reduce reliance on memory when assessing the patient’s risk
to reduce risk of harm to self or others

12. PSYCHOSOCIAL SCREENING TOOL
Do you have any problems (jobs, transportation, etc) that prevent you from keeping your health care appointments?
Do you feel unsafe where you live?
During the past year, has anyone hit you or tried to hurt you?
Do you or any members of your household go to bed hungry?
How do your rate your current stress level- low or high?
How many times have you moved in the past 12 months?
In the past 2 months, have you used any form of tobacco, drugs, or alcohol?
If you could change the timing of this pregnancy, would you want it earlier, later, not at all, or no change?
Adapted from: ACOG Committee Opinion, No (August, 2006). Psychosocial risk factors: Perinatal screening and intervention. Obstetrics and Gynecology, 108(2),

13. DEPRESSION/SUICIDE RISK ASSESSMENT
As the RN working with Ms. Johnson how often would you assess her psychosocial status, level of depression and risk for suicide?
According to ACOG, screening should be performed AT LEAST once each trimester. Problems may arise during the pregnancy that were not present at the initial visit.
What questions would you ask her?
ACOG Committee Opinion, No (August, 2006). Psychosocial risk factors: Perinatal screening and intervention. Obstetrics and Gynecology, 108(2),

14. DEPRESSION / SUICIDE RISK ASSESSMENT
Depression Risk Questions:
Over the past 2 weeks, have you ever felt down, depressed, or hopeless?
Over the past 2 weeks, have you felt little interest or pleasure in daily activities?
Suicide Risk Questions:
Do you have thoughts of injuring yourself?
Do you have thoughts of killing yourself?
(If yes) Do you have a plan?

15. DEPRESSION
Untreated depression has been associated with unfavorable health behaviors in pregnancy and may contribute to:
Fetal growth restriction
Preterm delivery
Placental abruption
Newborn irritability
ACOG Committee Opinion, No (August, 2006). Psychosocial risk factors: Perinatal screening and intervention. Obstetrics and Gynecology, 108(2),

16. RISK FACTORS
Ms. Johnson is at greater risk for which pregnancy complications as a result of her medical and social history?

17. RISK FOR PREGNANCY COMPLICATIONS
Ms Johnson’s medical and social history puts her at higher risk for:
Preeclampsia
Low birth weight infant
Preterm labor &/or preterm birth
Intrauterine growth restriction
Spontaneous abortion
Placental abruption

18. TEACHING
What are the priority teaching points to discuss with Ms. Johnson before she leaves the clinic today?
QSEN KSA: Patient Centered Care
Knowledge: Integrate understanding of multiple dimensions of patient-centered care, i.e. information, communication, and education

19. TEACHING Signs/symptoms of preeclampsia, preterm labor and abruption
Information and resources for support related to (r/t) safety at home, depression, suicide, drug use or any other concerns about caring for her self and her family
Stress importance of consistent prenatal care throughout the pregnancy
Smoking Cessation
Provide measures to support quitting

20. Signs & Symptoms Preterm Labor Preeclampsia Abruption Cramping
Continuous H/A
Elevated B/P
Edema
Epigastric pain
Shortness of breath
Dizziness
Decreased urinary output
Visual disturbances (blurred vision or spots)
Preterm Labor
Cramping
Pelvic pressure
Vaginal discomfort
Increased vaginal discharge
Loss of fluid
Vaginal bleeding
Feeling “not right”
Abruption
Abdominal tenderness
Low back pain

21. Ms. Johnson has been able to come to all but one of her scheduled prenatal visits. She has been taking her blood pressure regularly at home and reports a range of / She has denied symptoms of headache (HA), epigastric pain, visual disturbances, shortness of breath, dizziness. Urine dipstick at clinic visits has shown 0 to trace protein. Her asthma has been stable, with occasional use of her inhaler. She denies use of cocaine, other drugs, and alcohol. She states that she is “trying to smoke only 2-3 cigarettes / day” but sometimes smokes up to ½ pack on stressful days.

22. TRIAGE VISIT: AFTER A FALL
Ms. Johnson is now 27 weeks pregnant. She presents to the perinatal triage unit of the hospital reporting that she slipped and fell in the shower.
What are the priority nursing assessments at this time?
QSEN KSA: Patient-Centered Care
Skill: Engage patient or designated surrogates in active partnerships that promote health, safety, and well-being, and self care management.

23. PRIORITY NURSING ASSESSMENTS
Maternal VS
Fetal heart rate
Contractions (ask patient and use tocodynamometer)
Do you feel fetal movement? How often?
Are you having any vaginal bleeding? How many pads have you filled in the last hour?
Do you feel any vaginal discharge or leaking?
Are you having any abdominal pain or tenderness?
Review more specific history related to fall… determine if related to domestic abuse

24. Assessment data: Maternal VS: BP 154/82, HR 98, RR 20, T 98.80 F
FHR baseline: 150 with moderate variability; + accelerations noted; occasional variable decelerations noted
Occasional contractions: ~ 3-4/hour
+ fetal movement
No vaginal bleeding or loss of fluid
No abdominal pain or tenderness
Pt denies HA, visual disturbances, right upper quadrant pain; urine dipstick trace protein
Ms. Johnson denies that the fall resulted from any form of domestic violence; states that she does not feel unsafe in her home.

25. RHOGAM
After 2 hours of observation with no change in pt status, the physician orders administration of RhoGAM. Why?
What actions does the nurse need to take prior to administering this medication?
QSEN KSA: Safety
Knowledge: Describe processes used in understanding causes of error and allocation of responsibility and accountability
Skill: Demonstrate effective use of technology and standardized practices that support safety and quality

26. RHOGAM
Prevents formation of active antibodies against Rh+ erythrocytes which may enter maternal bloodstream during pregnancy with Rh+ fetus
Generally given at 28 weeks. Also given with:
Bleeding or suspected hemorrhage
Threatened abortion
Abdominal trauma
Prior to administration:
Send current type & screen
Indirect Coombs
Explain purpose and side effects; answer pt questions
Obtain informed consent
Verification by 2 RNs

27. Ms. Johnson is stable at home until 30 weeks gestation
Ms. Johnson is stable at home until 30 weeks gestation. At that time she is returns to the hospital complaining of vague lower abdominal pain with a gush of vaginal bleeding ~1 ½ hours ago, soaking 2 pads within 2 hours. The bleeding has tapered off to spotting. She reports + nausea and abdominal cramping; pain 3/10.

28. External fetal monitor (EFM) & Tocodynamometer (TOCO) are applied and show a FHR baseline of 150, moderate variability, occasional accelerations, no decelerations noted; + uterine irritability noted with mild contractions ~ 3-4 minutes apart
VS: BP 168/82; HR 102; RR 20;
T F
QSEN KSA: Informatics
Skill: Apply technology and information management tools to support safe processes of care; Use high quality electronic sources of healthcare information

29. What do you suspect may be occurring?
Based on the initial assessment, what are the priority nursing interventions for Ms. Johnson?

30. NURSING INTERVENTIONS FOR PLACENTA PREVIA/ABRUPTION
Notify MD
Explain situation to pt
ID and allergy bands
Continuous EFM & TOCO
Initiate pad count
Urine dipstick
Laboratory data
Type & screen
CBC
Coagulation studies
Chemistry profile
Urine analysis: including UDS
Large bore IV and fluids
QSEN KSA: Patient Centered Care
Attitude: Value seeing health care situations “through patient’s eyes”

31. NURSING INTERVENTIONS FOR PLACENTA PREVIA/ABRUPTION
Assess patient understanding of plan of care
Teach patient to notify RN of any changes
Explain procedures, answer questions and offer reassurance
Ensure that informed consents for surgery and blood transfusion are on chart
Suggest Neonatology consult
QSEN: KSA (next slide)

32. QSEN KSA: NURSING INTERVENTIONS FOR PLACENTA PREVIA/ABRUPTION
QSEN KSA: Patient-Centered Care
Skill: Provide patient-centered care with sensitivity & respect for the diversity of human experience; Assess own level of communication skill in encounters with patients and families
Attitude: Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care
QSEN KSA: Teamwork and Collaboration
Skill: Demonstrate awareness of own strengths and limitations as a team member
Attitude: Acknowledge own potential to contribute to effective team functioning
QSEN KSA: Safety
Skill: Demonstrate effective use of technology and standardized practices that support safety and quality

33. Placenta previa ruled out per ultrasound (us). No clots noted on u/s
Placenta previa ruled out per ultrasound (us). No clots noted on u/s. Speculum exam confirms ~10 mL blood in vault, no clots; 1 cm dilated visually. Vaginal bleeding continues: small amounts of occasional bright red spotting on pads. FHTs remain reassuring.
+ UDS
Patient admitted for high risk antepartum surveillance

34. At 2330, the nurse notes that FHR baseline has increased to 170 with no accelerations, and repetitive late decelerations. Vaginal bleeding has increased, and patient reports sharp abdominal pain (8/10) with uterine tenderness on palpation. Contractions have increased in frequency, ~ 2-3 min apart and uterus remains firm between contractions.
VS: BP 150/72 ; HR 110; RR 22; Temp F; Pulse oximeter (pox) on room air 96%

35. What are the priority nursing interventions at this time?
Notify the physician immediately
Plan for probable stat cesarean section
Call for additional help to prepare for surgery
Intrauterine resuscitation
IVF bolus, 10L O2 via face mask, pt to left lateral position
Frequent VS
Insert foley catheter & complete shave prep
Draw and send blood for type and cross-match; ensure MD order for blood products
Explain all interventions to patient and reasons for moving quickly
QSEN: KSA (next slide)

36. QSEN KSA: Priority Nursing Interventions for Abruption
QSEN KSA: Safety
Skill: Demonstrate effective use of strategies to reduce risk of harm to self and others
Attitude: Value own role in preventing errors
QSEN KSA: Teamwork and Collaboration
Knowledge: Describe own strengths, limitations & values as a team member
Skill: Demonstrate awareness of own strengths & limitations as a team member; assume role of team member or leader based on the situation; initiate requests for help when appropriate to situation; integrate contributions of others who play a role in helping patient/family achieve health goals
Attitude: Acknowledge own potential contributions to effective team functioning

37. ID band is in place and pt is correctly Identified by 2 identifiers
TO ENSURE MS. JOHNSON’S SAFETY IN THE OPERATING ROOM (OR), WHAT VERIFICATIONS MUST BE COMPLETED PRIOR TO TRANSFER?
ID band is in place and pt is correctly Identified by 2 identifiers
All jewelry, clothing, metal removed
Confirm allergies
Verify informed consents for surgery and blood transfusion on chart
QSEN KSA: Safety
Skill: Demonstrate effective use of strategies to reduce risk of harm to self and others

38. Physician immediately notified and at bedside; pt is 6/90/-1 on vaginal exam with moderate bright red vaginal bleeding
Maternal VS: BP 120/60, HR 108, RR 23,
T 99.40F, pox 100% on 10L O2; patient very anxious
FHTs continue to be ominous with repetitive late decelerations
Multidisciplinary team mobilized for stat cesarean section

39. OPERATING ROOM
In the OR, one RN is responsible for circulating, and you are responsible for baby care and resuscitation, with the team from the neonatal intensive care unit (NICU). The team from the NICU is waiting in the OR and report is given. After a “time out” the patient goes under general anesthesia and the baby is born ~ 3 minutes later. Apgars were 5 at one minute, and 7 at five minutes.
QSEN KSA: Safety
Skill: Demonstrate effective use of strategies to reduce risk of harm to self and others
Attitude: Value own role in preventing errors

40. TRANSFER TO NICU
Prior to transfer to the NICU, what priority action must the NICU nurse take?

41. TRANSFER TO NICU
The baby must be properly identified via 2 bands with mother’s name, baby’s date and time of birth. Also, footprinting and band ID number should be confirmed by another RN and matching bands applied to mother & significant other prior to transfer to NICU.
QSEN KSA: Safety
Skill: Demonstrate effective use of strategies to reduce the risk of harm to self or others
Attitude: Value the contributions of standardization/reliability to safety; appreciate the cognitive and physical limits of human performance; value own role in preventing errors

42. PATIENT TRANSFER
Ms. Johnson is transferred from the OR to the recovery room, and then to the postpartum unit.
What should be included in the SBAR report?

43. SBAR REPORT Situation Background Assessment Recommendations
Mom: Name, room #, physician,
time/type of delivery, assistive instruments
Infant: gestational age, sex, weight, apgars, feeding type
Background
Patient prenatal history and history since admission
Assessment
Mom: vital signs, BUBBLEHEP findings
Infant: vital signs, dextrostix, abnormal assessment findings
Recommendations
Newborn initial eye care, Vitamin K
QSEN: KSA (next 2 slides)

44. QSEN: PATIENT TRANSFER
QSEN KSA: Teamwork and Collaboration
Skill: Assume role of team member/leader based on situation; function competently within own scope of practice as member of health care team; integrate contributions of others who play a role in helping patient/family achieve health goals; follow communication practices that minimize risks associated with handoffs among providers and across transitions
QSEN KSA: Patient-centered Care
Knowledge: Integrate understanding of multiple dimensions of patient centered care: information, communication, and education

45. QSEN: PATIENT TRANSFER
QSEN KSA: Safety
Skill: Use appropriate strategies to reduce reliance on memory
Attitude: Value the contributions of standardization/reliability to safety; appreciate the cognitive and physical limits of human performance; value own role in preventing errors
QSEN KSA: Quality Improvement
Skill: Use tools to make processes of care explicit

46. PATIENT TRANSFER
The postpartum nurse does the initial assessment and the patient’s condition is stable. She tells her that her family is in the waiting room, asking to see her. She asks her if she is ready for visitors.
Her family arrives and are elated about the new addition to the family!
QSEN KSA: Teamwork & Collaboration
Knowledge: Recognize contributions of other individuals & groups in helping patient/famlly achieve health goals.
Skill: Integrate the contributions of others who play a role in helping patient/family achieve health goals.
Attitude: Respect the centrality of the patient/family as core members of the health care team.

47. NURSING DIAGNOSES AND INTERVENTIONS
Identify 3 nursing diagnoses and 2 nursing interventions that would apply to the patient at this time
Identify 3 nursing diagnoses and 2 nursing interventions that would apply to the newborn at this time

48. N-CLEX STYLE PRACTICE QUESTION
A patient is admitted with abruptio placentae. The nurse should assess the patient for which of the following signs and symptoms? (Select all that apply)
Vaginal bleeding that is concealed or apparent
Abdominal pain
Board-like abdomen
Large placenta
Incontinence
Answer: a, b, c

49. N-CLEX STYLE PRACTICE QUESTION
A patient is admitted for preterm labor at 33 week’s gestation. The nurse administers betamethasone (Celestone). What is the purpose of giving this drug?
To stop the patient’s labor
To decrease the patient’s pain level
To promote infant surfactant production
To prevent a complicated delivery
Answer: c