UNIVERSITY OF PERPETUAL HELP SYSTEM - ISABELA

CAMPUS
Minante Uno, Cauayan City, Isabela

Introduction

For this second rotation of RLE duty, the BSN IV Group 6 students were assigned for

four consecutive weeks at Echague District hospital in Delivery Room, Operation room and

emergency area. Our shift was 7 – 3 pm in OR, DR, ER.

Unfortunately, we never handled a patient suffering from complications area of this

case to present I discuss this because this is very rare to know.

Hemolytic disease of a newborn is sometimes left unknown. We never had the chance

to understand this case because we feel that is it’s not important.

The group has these objectives for our case. We want to familiarize ourselves about

haemolytic disease of a newborn, be able to differentiate types of blood, to enhance ourselves

how fetal circulation happens, to understand deeply about Rh groups and ABO Groups . Most

important being a nursing student, we must know how this disease will occur.

About the different diagnostic procedures and what are the effective nursing

interventions when handling this type of case. We also included here the different medical

management both pharmacologic and non pharmacological.

 Hemolytic Disease of the Newborn

This can occur only if antigens on fetal on erythrocytes differ from antigens on
maternal erythrocytes. Maternal-fetal incompatibility exists if mother and fetus differ in ABO
type or if the fetus is Rh positive and the mother is Rh negative.

Other Name

Erythroblastosis Fetalis

Types
 Rh Incompatibility
 Occurs when the mother is Rh-negative and the fetus is Rh-positive
 Fetal blood and maternal blood are separate. Sometimes, accidental breaks in
the placental villi results fetal blood entering the maternal blood stream.
 If the fetal blood is Rh-negative, and the maternal blood is Rh-positive, the
mother will recognize the fetal blood as foreign bodies and will produce
against it. Only a few antibodies are formed this way so that it usually does not
affect the first infant
 During placental separation a great amount of maternal and fetal blood are
mixed, causing the mother to produce large amount of antibodies during the
first 72 hours after placental delivery. Since the infant is already delivered at
this time, the infant will not be affected
 If the fetus in subsequent pregnancies is Rh-positive, the antibodies already
present in the maternal bloodstream will attack and destroy the fetal blood
cells resulting in fetal anemia

 ABO Incompatibility
 Occurs when maternal blood type is O and fetus is:
TYPE A- most common
TYPE B- most serious
TYPE AB- rare
 A and B antibodies are present in bloodstream at birth so hemolysis of fetal
blood may occur during the first pregnancy
 The antibodies are the large IgM type so it does not cross the placenta during
pregnancy
 During separation of the placenta, maternal blood mixes with fetal blood
resulting in antibodiesof the nother entering the bloodstream of the infant. This
antibodies begin to hemolyze the fetal RBC after birth
Incidence rate

 ABO Incompatibily

It occurs in about 20-25% of all pregnancies, but only in one to ten cases of
ABO Incompaibility results in HDN.

 Rh Incompatibity

It occurs in fewer than 10% of pregnancy in rarely causes HDN in the first
incompatible fetus. Even after five or more pregnancies. Only 5% of women have
babies with hemolytic disesase.

Anatomy and Physiology

 Fetal circulation

The circulatory system of a human fetus works differently from that of born humans,
mainly because the lungs are not in use: the fetus obtains oxygen and nutrients from the
mother through the placenta and the umbilical cord
  BLOOD 
            A.  Composition
                        1.  formed elements
                                    a.  erythrocytes (RBC)
                                    b.  leukocytes (WBC)
                                    c.  platelets

                  
                        2.  plasma
                                    a.  fluid
                                    b.  proteins
c. other solutes ( ions, nutrients.gas, waste products )
            B.  Function to maintain homeostasis                    

 Erythrocytes                                                                                             
             A.  Function
                        1.  (Oxygen) gas transport
                        2.  hemoglobin structure
            B.  RBC
                        1.  formation from hematocytoblast in red marrow
                        2.  loss of organelles
                        3.  biconcave shape
                        4.  structure and function correlation
            C.  Life cycle
                        1.  erythropoiesis
                                    a.  negative - feedback regulation
                                                1.  erythropoietin
  Red blood cell production
         
D. Surface markers (antigens)                                                     
                        1.  ABO group
                                    a.  type A:  A antigens, antibodies to B in plasma
                                    b.  type B:  B antigens, antibodies to A in plasma
                                    c.  type AB:  both A and B antigens, no antibodies in plasma
                                    d.  type O:  no antigens, antibodies to both A and B in plasma
                        2.  agglutination reaction:  antibody “clumps” antigens
                        3.  Rh system                            
                                    a.  Rh+:  Rh antigen
                                    b.  Rh- :  no Rh- antigen (no antibodies to Rh+ unless exposed to Rh+
antigen)
                                    c.  hemolytic disease of newborn
                                                1.  Rh-  mom and Rh+  fetus
                                                2.  Rhogam
Blood groups

The ABO blood groups, there are two different types of agglutinogens (antigens):
type A agglutinogens and type B agglutinogens. These agglutinogens may or may not be
present on the surface of red blood cells in four different combinations:

 Blood type A à type A antigen are present on the surface of red blood cells
 Blood type B à type B antigen are present on the surface of red blood cells
 Blood type AB à both A and B antigens are present on the surface of red blood cells
 Blood type O à neither A or B antigens are present on the surface of red blood cell
Signs and Symptoms

The mother will not experience any signs and symptoms unless the baby dies in the
utero and is not born right away. She will not notice the cessation of pregnanacy signs and
symptoms and the fetal movement she has felt before, but she will not directly related to
erythroblastosis fetalis.

The baby will experience the following after birth:

 Dehydration
 Dark green stool
 Dark brown skin
 Dark colored urine
 Excessive weight loss
 Apnea
 Tachypnea
 Temperature instability

Complications

During Pregnancy:

 Anemia
 Hepatomegaly
 Splenomegaly
 cardiomegaly
 Hydrops fetalis

After birth:

 Hyperbilirubinemia
 Kernicterus

Diagnostic procedures

 Coombs’ test (Indirect Coombs’ test and Direct coomb’s test)

 Serum Bilirubin levels
 Blood test
 Neonatal antibody titer
 Fetal blood sampling
 Amniotic fluid sprectophototherapy
 Ultrasound fetal assessment
Medical management

 RhoGam (human immune globulin)- this can be given if Direct and Indirect Coombs’
test are negative to prevent development of anti-Rh-positive antibodies as the result of
sensitization of present pregnancy
 Non-pharmacological management
 Phototherapy- speeds up the maturation of RBC to prevent
accumulation of indirect bilirubin
 Blood transfusion- immediately removes 85% of sensitized RBC,
reduce bilirubin levels and prevent congestive heart failure
 DIAGNOSIS PLANNING
Ineffective tissue
perfusion related to  After 1-2 hours of
destruction of RBC as nursing intervention the
manifested by pale, patient will be able to
pallor, increase demonstrate increased
respiratory rate, increase perfusion from
pulse rate, increased increased respiratory
capillary refill>3 sec rate and pulse rate to
normal range
 After 1-2 days of
nursing intervention the
patient will be able to
improve circulation
DIAGNOSIS PLANNING
INTERVENTION RATIONALE
Independent :
 Position the client in a supine -to facilitate equal distribution of
position blood
 Loosen tight clothing -to promote better circulation
 Provide quiet, calm and clean -to promote adequate rest
environment
 Advice the mother to cuddle the -to promote bonding and relaxation
baby
 Provide appropriate ventilation -to promote humidification
Dependent :
 Administer oxygen at 2-4L/minute -to increase oxygen supply
as ordered
 Administer blood transfusion as -to replace the destruct RBC
ordered
Interdependent :
 Cross-matching before blood -to prevent blood incompatibility
transfusion
and blood transfusion
INTERVENTION RATIONALE
 Fluid volume excess  After 1-2 hours of
related to organ failure nursing intervention the
( cardiomegaly)as patient will be able to
manifested by presence demonstrate normal
of edema, crackles, breathing pattern and
dyspnea, increase blood airway clearance
preasure and poor skin  After 1-2 days of
turgor nursing intervention the
patient will be able to
stabilize fluid volume as
evidenced by free of
sign of edema
Dependent :
DIAGNOSIS PLANNING
Independent :
 Advice the patient to restrict
sodium and fluid intake
 Set appropriate fluid intake
throughout 24 hours period
 Elevate edematous extremities and
change position frequently
 Place in Semi- Fowler’s position
 Turn and reposition client every 2
hours
 Advice the patient to void when
there is an urge
 Administer diuretics as ordered
INTERVENTION
-to avoid increase accumulation of
fluid
-to prevent peaks in fluid level and
thirst
-to reduce tissue pressure and risk
for skin breakdown
-to facilitate movement of
diaphragm, thus improving
respiratory effort
-to protect edematous tissue
- to reduce excess fluid
-to promote fluid elimination
RATIONALE
 Decreased Cardiac  After 2-4hours of
Output related to altered nursing intervention,
contractility as the patient will be able
manifested by to demonstrate an
orthopnea, nocturnal increase in activity
dyspnea, restlessness, intolerance and
fatigue and palpitation participate in activities
that reduce the workload
of the heart
Independent :
 Provide quiet, calm and clean
environment
 Provide appropriate ventilation
 Position the client into Semi-
Fowler’s position
 Elevate legs when in sitting
position
 Elevate edematous extremities
 Avoid restrictive clothing
-to promote adequate rest
-to promote humidification
-to facilitate movement of
diaphragm, thus improving
respiratory effort
-to enhance venous return
-to reduce tissue pressure and risk
for skin breakdown
-to promote better circulation

Dependent :
 Administer high flow of oxygen
via mask or ventilator as indicated
 Give drugs and IV fluids as
ordered
-to increase oxygen available for
cardiac function
-to promote wellness of the client