Question

Dylan is a 36 year old female who has come for a routine 28 week prenatal check-up. She is a non-smoker, is physically active and has gained 4 kg of weight so far in her pregnancy. Dylan’s obstetrical history is G2 T0 P0 A1 L0.  Both pregnancies have been assisted with in-vitro fertilization.  During this first trimester, Dylan has suffered from nausea and vomiting but it has now resolved.  Now, Dylan states she is exhausted all the time.  The fetus is active and Dylan has been keeping track of movement by daily kick counts.  Dylan’s blood pressure has been stable throughout the pregnancy.

You are the clinic nurse for the day and are caring for Dylan during her prenatal appointment.

4. What diagnostic tests would you anticipate the primary care provider ordering if there were an abnormal fundal height?

The next step in your prenatal check is to auscultate the fetal heart rate.

5. Describe the steps to take when assessing the fetal heart rate.

You listen for one minute and find that the fetal heart rate is 130bpm with regular rhythm and no decelerations heard.

6. Discuss the significance of these findings.

Outside the exam room, you provide a report to the primary care provider of all assessment findings and mention that Dylan states she feels exhausted all of the time.  The primary care provider goes in to assess the patient.  Dylan restates the constant feeling of exhaustion and the primary care provider orders a complete blood count to be done prior to the next visit.  

7. Why do you think the physician is ordering a complete blood count?

Two weeks later, Dylan returns for a follow-up prenatal visit.  Dylan states that the fetus is moving, but the exhaustion remains, and she has now started to feel dizzy occasionally and finds it is hard to catch her breath.  Dylan’s blood work results are on file and show the following:

• RBC - 3.0 x 10¹²/L
• WBC – 7 x 10⁹/L
• Hct – 0.30
• Hgb – 109 g/L

8. What are five potential impacts to the pregnancy and fetus if these values are not corrected?
9. What medication would you anticipate the primary care provider to order based on the above lab results? Provide your rationale.
10. What five teaching points would you provide around this medication and her condition?

The rest of Dylan’s prenatal check-up is unremarkable and she is about to leave with her prescription.  

11. List four priority teachings you would provide at the end of this appointment.

Answer 1

Present clinical condition of Dylan :

• Dylan is 36 years old with second pregnancy is under antenatal check of 28 weeks. Her Obstertrical score is G2 T0 P0 L0 A1.
• Above obstetrical score clearly shows that Dylan was not a full term pregnant in the previous pregnancy and was aborted .
• In the present pregnancy Dylan gained 4 kgs of weight , she had nausea and vomiting which got resolved now, where as Dylan says that she is so exhausted all the day, Fetus is very active and she keep on counting kicks of the baby.

​​​​​​​As a clinical nurse taking care of Dylan

Tests that would be anticipated for abnormal fundal height:

Fundal height is one of the indicator for accurate fetal growth.Fundal height can be measured from symphysis pubis to the xiphoid process of the mother.This can be measured through ultrasound or also finger breadth method.

For e.g.. At 16 weeks the uterine fundal height will be at symphysis pubis

At 24 weeks at the level of the umbilicus

From there using four fingers fundal height can be calculated as 28 weeks,32 weeks and 36 weeks I.e. at 36 weeks the fundal height reaches xiphoid process which makes the mother feel so uncomfortable during sleep and also leads to difficulty in breathing and digestion abnormalities.

Where as again at 40 weeks durle to engagement the fundal height descends down at the level of 32 weeks. This type of assessing fundal height is called finger breadth method. Also t fundal height can be measured in cms with the help of inch tapes.

Diagnostic tests :

Ultrasound can be done to visualize the Fetus cross sectionally to know the fetal length I.e. height and also arm circumference.Estimated weight of the baby more than 90 percentiles indicates Larger for the fetal dates.

Assessing Fetal Heart Rate for Dylan :

• This can be assessed either in semi sitting or supine position, As Dylan is feeling exhausted so make her to semi sit in a comfortable posture.
• Assure Dylan that this is a normal process of hearing your baby heart sounds.
• This can be monitored by stethoscope, fetoscopes and also Doppler method.
• Feral heart sounds are best audible through left scapular region in vertex and breech presentations
• For the fetal heart sounds to hear the clinical nurse must be well aware of the positions, presentations and the location for the access of Feral heart sounds.

​​​​​​​Discuss the significance findings.

Findings identified after checking the heart sounds for one full minute is 130 beats / min , with regular rhythm and no deceleration heard.

Normal Feral Heart Sounds are 120 to 140 beats per minute,here found to be 130 with regular rhythms.

Deceleration is decrease in the fetal heart rate than normal.So explain to Dylan about the findings stating that those were normal for the Baby.

Reason for the Physician ordering complete blood count

• Dylan is exhausted always feeling tierd
• This is to check her Blood count I.e. erythrocyte count especially to find out whether Dylan is Anaemic or lesser haemoglobin than required.

​​​​​​​For the next visit 2 weeks later Dylan blood work up results shows

RBC 3.O× 1012/L ,where as normal should be 4.5 to 6 millions per microlitres

Haematocrit should be 35 to 48 but Dylan have 0.30

Haemoglobin is 10.9gm/dl, which indicates that Dylan is suffering with Anaemia.

Potential Impacts of Anaemia on Baby and Mother:

• Risk of prematurity
• low birth weight baby
• Intrauterine Death

​​​​​​​Mother : Maternal mortality and morbidity is the main risk.

Medication to be administered is

Injections of Ferrous Sulphate in Severe cases to improve Hb fastly.

Folic acid and vitamin supplements.

Teachings can be provided :

1. Educate the mother about the severity of the condition
2. Explain her about the importance of taking medications both for her and her baby
3. Make her understand about the potential risks and complications if medications were discontinued
4. List out the iron rich foods that she has to consume.
5. Explain her regarding the medications in detail.

Priority teachings :

Medication advice

Food and Dietary patterns

Regular intake of Medications

Regular follow up for the increased Hb