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Case Study Labour Room
Case Study Labour Room
Case Study Labour Room
FETAL DISTRESS
Compromise of the fetus during the antepartum period (before labor) or intrapartum period
(birth process). The term "fetal distress" is commonly used to describe fetal hypoxia (low
oxygen levels in the fetus). The concern with fetal hypoxia is it may result in fetal damage or
death if not reversed or if the fetus is not promptly delivered.
Fetal distress can be detected due to abnormal slowing of labor, the presence of meconium
(dark green fecal material from the fetus) or other abnormal substances in the amniotic fluid,
or via fetal monitoring with an electronic device showing a fetal scalp pH of less than 7.2.
Fetal distress, also more commonly known as “nonreassuring fetal heart tracing”, is basically
a particular complication when during labor your baby’s heart beat becomes flat, or drops to a
lower level repeatedly causing stress for your baby. When you are in labor your baby’s heart
rate will constantly be monitored for any sign of complications or stress.
Early - These are usually indicative of a head compression and are the most common of all
three.
Variable - These are usually indicative of a cord compression and are usually seen in the
pushing stage of labor.
Late - These are the ones which usually cause the most concern. A single deceleration may
not be so bad, but persistent late decelerations are usually followed by concern for the baby’s
well being.
I. Risk Factors
V. Shoulder dystocia
X. Uterine rupture
While some change in fetal heart pattern during labor is fairly normal, there are also a variety
of different factors which may cause fetal distress. Some of the common causes include:
A loop of umbilical cord around the baby's neck. Almost 30% of babies have a cord around
their neck
Uterine infection
Placental abruption
Uterine rupture
-Compromise of the fetus during the antepartum period (before labor) or intrapartum period
(birth process)
-commonly used to describe fetal hypoxia (low oxygen levels in the fetus)
-Fetal distress can be detected due to abnormal slowing of labor, the presence of meconium
(dark green fecal material from the fetus) or other abnormal substances in the amniotic fluid,
or via fetal monitoring with an electronic device showing a fetal scalp pH of less than 7.2.
Etiology/Risk factors:
Maternal
-poor placental perfusion
-hypovolemia
-hypotension
-myometrial hypotonus: prolonged labor, excess oxytocin
-with cardiac problems
-<35 y/o and 16 below
Fetal
-cord compression: oligohydramnios, enlargement, prolapsed
-infection
-nuchal cord
-pre-existing hypoxia
REAL CASE
A) Patient History
Real case I studied is Fetal Bradycardia in general known as fetal distress. Patient name, Fatin
Nur Syafiqah Binti Saiful Nizam (RN 5015), Malay and 26 years old women came to Labor
room from Ward 3 on 7 August 2019 at 8.00 am for the delivery. She accompanied by her
husband. The chief complaint made by this patient is leaking of liquor. Next, the history of
presenting complaint made by this patient is, 26 year-old Malay, gravida 2 para 1 at 35 weeks
+ 6 days period of gestation was admitted to Hospital Slim River for elective lower segment
caesarean section due to fetal bradycardia.The patient came to Hospital Slim River after being
scheduled for elective lower segment caesarean section today, 8 of August 2019, in the
afternoon.At 21 weeks period of gestation during her booking, she was diagnosed to have
gestational diabetes mellitus after being tested for modified glucose tolerance test. She was
only advised to control her diet and was not prescribed on any medications. After had a
conversation with this patient, we get to know that she does not have any past medical and
surgical history.
Physical Exam
Linea Nigra
Striae
gravidarum
During general examinations, this patient is look alert, pink, conscious and good hydration.
The vital sign of this patient is,
Initial Current
Cardiovascular system is shown dual rhythm no murmur (DRNM) and S1S2 heard clearly.
When auscultate the lungs, air entry show equal and clear. During palpitation, stomach shows
in soft, non-tender, no mass condition and bowel sound active also found in stomach. Other
physical examination found in her body is back pain and abdominal pain caused by contraction.
No edema and varicose vein seen on both feet.
B) Differential diagnosis
The differential diagnosis that can made is caesarean and assisted vaginal delivery (AVD).
Investigation
After undergo the patient’s history, physical examination and finding differential diagnosis,
next doctor carry out some laboratory and radiology investigation. For laboratory test, full
blood count (FBC) were taken. The result is as shown below:
Automated differentials:
UFEME Result
Leucocyte Negative
Nitrite Negative
Urobilinogen Normal
pH 6.5
Protein Negative
Blood Negative
Ketones Negative
Bilirubin Negative
Glucose Negative
C) Diagnosis
Fetal Distress(Bradycardia)
Ward Management
The routine ward management done to this patient is taking cardio tocography (CTG), and plot
patograph, doing bed making in the morning, checking patient’s vital sign 4 hourly, give
medication to the patient in correct dosage based on doctor’s order. Other routine ward
management is observing the branula intact of this patient to avoid from occurring bleeding
and strict input and output I/O charting. Not only that, other routine ward management is giving
nursing care and always observe this patient rest on bed.
While the specific ward management send this patient to labour room for artificial rupture of
membrane and for delivery. Other specific management is inserting Foley catheter to mother
before delivery to empty the bladder, monitoring blood sugar level 4 hourly, encourage mother
to breast feed her baby, give an oxytocin vaccines to mother and give BCG and Hepatitis B
vaccines to baby after delivered.
Post-Operative Management
Uterus contracted and refracted well. No active per vaginal bleeding seen.
-Prevention and
control of
nausea and
vomiting
Eat medications followed by the dosage that has been prescribed by doctor
Do simple exercise
Take an immunization of the baby like BCG and Hepatitis B properly as early as
possible
Walk
Contraceptive for two years – injectible, oral POP, IUCD (cannot give COCP;
breastfeeding(
REFERENCE A
DEFINITION
• Cardiotocography signs
• Biochemical signs, assessed by collecting a small sample of baby's blood from a scalp
prick through the open cervix in labour
– fetal acidosis
– elevated fetal blood lactate levels indicating the baby has a lactic acidosis
– Some of these signs are more reliable predictors of actual distress than others.
For example, cardiocartography can give high false positive rates, even when
interpreted by highly experienced medical personnel. Acidosis is a highly
reliable predictor, but is not always available. A highly effective method of
assessment of distress would be to use fetal heart rate as a first indicator of
distress, to be confirmed with a more reliable method of diagnosis before radical
treatment is performed
CAUSE
• Breathing problems
• Multiple births
• Shoulder dystocia
• Nuchal cord
• Placental abruption
RISK FACTOR
– Stillbirth
– Oligohydramnios or polyhydramnios
– Multiple pregnancies
– Rhesus sensitisation
– Hypertension
– Post-term pregnancy.
• There is some evidence that maternal age over 35 years is an independent risk factor
for uteroplacental insufficiency and fetal distress
TREATMENT
In many situations fetal distress will lead the obstetrician to recommend steps to urgently
deliver the baby. This can be done by induction, or in more urgent cases, a caesarean
section may
• Normal range at term is 120-160 bpm.
Late decelerations, defined as uniform,repeated, periodic slowing of the fetal heart rate, whose
onset is from mid to end of the contraction, with its nadir more than 20 seconds after the peak
intensity of the contraction, suggest fetal hypoxia
REFERENCE B
Fetal Distress
Fetal distress is a condition in which the fetus (unborn baby) develops a problem during
the mother’s labor.
Compromise of the fetus during the antepartum period (before labor) or intrapartum
period (birth process).
The term "fetal distress" is commonly used to describe fetal hypoxia in utero (low oxygen
levels in the fetus).This occurs when conditions which interfere with the supply of oxygen
to the foetus are present.
It is ill defined term , used to express intrauterine fetal jeopardy, a result of intrauterine
fetal hypoxia.(Dutta)
The concern with fetal hypoxia is it may result in fetal damage or death if not reversed or
if the fetus is not promptly delivered.
Fetal distress can be detected due to abnormal slowing of labor, the presence of
meconium (dark green fecal material from the fetus) or other abnormal substances in the
amniotic fluid, or via fetal monitoring with an electronic device showing a fetal scalp pH
of less than 7.2.
Fetal Hypoxia
Metabolic acidosis
H-ions first stimulate and then depress the Also causes parasympathtic
sino-auricular node stimulation
Note: A normal fetal heart rate may slow or fast during a contraction but usually recovers to
normal as soon as uterus relaxes.
Fetal distress can occur during pregnancy, or more commonly during labour. Fetal Distress
can be due to a wide range of reasons. The main cause of antepartum fetal distress is
uteroplacental insufficiency.
Factors within labour are complex but processes such as uteroplacental vascular disease,
reduced uterine perfusion, fetal sepsis, reduced fetal reserves, and cord compression can be
involved alone or in combination, and gestational and antepartum factors can modify the
fetal response. Reduced liquor volume, maternal hypovolaemia and fetal growth restriction
are known associations.
Placental insufficiency. This is when the placenta is not functioning at its best and
can be due to high blood pressure, heart conditions, bleeding in late pregnancy,
small baby or post dates, Pre-eclampsia, eclampsia, chronic nephritis and DM.
A sharp drop in the mother's blood pressure due to her having an epidural, or
experiencing a haemorrhage, or lying for a prolonged period flat on her back in
labour.
Cord compression due to an early artificial rupture of the membranes (ARM) or a
cord prolapse. The blood supply may also be reduced if the umbilical cord is
wrapped several times around the baby's neck or body.
Placental abruption (or separation of the placenta from the wall of the uterus),
Placenta previa.
An inherited disorder.
During uterine contractions compression of the fetal skull causes vagal stimulation, which
slows the fetal heart rate. Head compression usually does not harm the fetus. However, with a
long labour due to cephalopelvic disproportion, the fetal head may be severely compressed.
This may result in fetal distress.
REDUCED BLOOD FLOW THROUGH THE PLACENTA: The placenta may fail to
provide the fetus with enough oxygen and nutrition due to a decrease in the blood flow
through the placenta, i.e. placental insufficiency. Patients with pre-eclampsia have poor
formed spiral arteries that provide maternal blood to the placenta. This can also be caused by
narrowing of the uterine blood vessels due to maternal smoking.
ABRUPTIO PLACENTAE: Part or all of the placenta stops functioning because it is
separated from the uterine wall by a retroplacental haemorrhage. As a result the fetus does
not receive enough
oxygen.
CORD PROLAPSE OR COMPRESSION: This stops the transport of oxygen from the
placenta to the fetus.
A reduction in the normal supply of oxygen to the fetus causes FETAL HYPOXIA. This is a
lack of oxygen in the cells of the fetus. If the hypoxia is mild the fetus will be able to
compensate and, therefore, show no response. However, severe fetal hypoxia will result in
FETAL DISTRESS. Severe, prolonged hypoxia will eventually result in fetal death.
Hypoxia
Metabolic acidosis
Asphyxia
Tissue damage
Fetal death
Management
In many situations fetal distress will lead the obstrecion to recommend steps to urgently
deliver the baby. This can be done by induction, or in more urgent cases, a caesarean section
may be performed.
Prop up the woman or place her on her left side, which helps to improve placental
circulation. Lateral positioning avoids compression of venacava and aorta by the
gravid uterus. This increase cardiac output and uteroplacental perfusion.
Stop oxytocin if it is being administered.
Correction of dehydration by IV fluids improves intravascular volume and uterine
perfusion.
Correction of maternal hypotension, following epidural analgesia, with immediate
infusion of 1 litre of crystalloid (RL)
Tocholytic (inj turbutaline 0.25 mg sc) is given when uterus is hyppertonus and there
is non reassuring FHR.
Aminio-infusion has been shown to be beneficial in this situation, with a reduced risk
of Caesarean section This an initial infusion of a 250-500ml bolus of warmed normal
saline, through a double lumen intrauterine pressure catheter. (Uterine pressure and
fetal heart rate (via scalp electrode) are monitored constantly.) It is thought to dilute
meconium and reduce the risk of meconium aspiration and reduces cord compression.
The potential adverse effects include umbilical cord prolapse, uterine scar rupture and
amniotic fluid embolism.
Check uterine contraction for strength, duration of fregnancy.
MECONIUM
Meconium staining of amniotic fluid is seen frequently as the fetus matures and by
itself is not an indicator of fetal distress. A slight degree of meconium without fetal
heart rate abnormalities is a warning of the need for vigilance.
A normal fetal heart rate may slow during a contraction but usually
recovers to normal as soon as the uterus relaxes.
A very slow fetal heart rate in the absence of contractions or persisting
after contractions is suggestive of fetal distress.
A rapid fetal heart rate may be a response to maternal fever, drugs causing
rapid maternal heart rate (e.g. tocolytic drugs), hypertension or amnionitis.
In the absence of a rapid maternal heart rate, a rapid fetal heart rate should
be considered a sign of fetal distress.
DISCUSSION
SIMILARITY
Based on my case study, there have a few similarity I found in real case, Reference A
and Reference B. First similarity I found in this three cases is its definition. These three cases
stated fetal distress is describe fetal hypoxia (low oxygen levels in the fetus). The concern with
fetal hypoxia is it may result in fetal damage or death if not reversed or if the fetus is not
promptly delivered. It can be detected due to abnormal slowing of labor, the presence of
meconium (dark green fecal material from the fetus) or other abnormal substances in the
amniotic fluid, or via fetal monitoring with an electronic device showing a fetal scalp pH of
less than 7.2.
Next similarity I found from the real case and the references is the sign and symptom.
the reference A, B and real case said that there decreased movement felt by the mother
Meconium in the amniotic fluid Cardiotocography signs increased or decreased fetal heart rate
(tachycardia and bradycardia), especially during and after a contraction. decreased variability
in the fetal heart rate.
Other similarity found from Reference A, B and real case is the causes of fetal distress.
Medical staff in real case and Reference A and B mentioned the indication of fetal distress is
lack of oxygen. The most common reason for fetal distress is the baby is not receiving enough
oxygen when inside the uterus. This is usually because there is not an adequate blood flow
through the placenta and cord. When the uterus contracts during labour, it momentarily reduces
blood flow to the baby, as the uterus relaxes, the blood flow increases. This is a normal, natural
process that healthy babies, with a healthy placenta, are not concerned with. In fact, it actually
stimulates the baby (usually shown as an increase in their heart rate).
There are some situations when the blood flow (and hence the oxygen supply), are lessened,
causing the baby to become either slowly distressed over time, or suddenly distressed.
Next similarity from these three cases is the complication of the fetal distress. Real case
and these two references mentioned the complication maybe faced by the mother after
delivered is labour and shoulder dystocia, breech presentation, post-partum hemorrhage which
defined as an excess blood loss from the uterus (more than 500 mL) during and after delivery.
Other complication is cord prolapse, meconium, vacuum assisted delivery and non-progression
of expulsion for example the head or presenting parts are not delivered despite adequate
contractions.
As a conclusion, we can understand that the real case, Reference A and B are used same
definition of fetal distress, sign and symptom,causes.