RAJKUMARI AMRIT KAUR, COLLEGE OF NURSING, LAJPAT NAGAR, DELHI

CARE PLAN
ON

PROM WITH SEVERE

OLIGOHYDRAMNIOS

SUBMITTED TO: SUBMITTED BY:

Dr. (Mrs.)MOLLY BABU SAVITA
HOD (OBS $ GYNE) Msc NURSING
IDENTIFICATION DATA

Name: - Ankesh

Age & Sex: - 26yrs/female

Ward & unit: - wd-3/unit-4

Bed no.: -9

Reg. No. : - PAN-17-18196

Mother’s Occupation: - housewife

Husband’s occupation: - Private work in bank

Education: - 12th pass

Address: - F-4/9, Malviya Nagar New Delhi

Date of Admission: -11 feb. 2017

Income: - Rs. 17000-20000 per month

Gravid: - Primi

Diagnosis: - Primi with 29 week with PROM with oligohydramnios

High risk Score: -6

High risk Factors: - Oligohydramnios (2), Leaking Per Vagina(2), maturity less than 37 week(2)

SUBJECTIVE DATA

1. ADMISSION HISTORY: Patient came with the complaining of leaking per vagina since 27/1/2017 in the
emergency.

1. PERSONAL HISTORY: She is married for 5 yrs . They live in their own house have two rooms and separate
kitchen and bathroom.
She is a vegetarian and has a normal bowel pattern. No habit of tobacco chewing or smoking. She has
normal sleep pattern of 7-8 hrs a day.

2. MEDICAL HISTORY: Patient have No history of T.B, HTN. No history of any skin infection.

3. SURGICAL HISTORY: No history of previous surgery.

1. FAMILY HISTORY: Ankesh and her husband lives in a nuclear family in Delhi. Her husband is the only
earning member. Rest of the family members live in village.
Ankesh’s family members have no history of T.B., DM, HTN and epilepsy.

4. MENSTRUAL HISTORY: She attained her menarche at the age of 14 years. She had regular cycle of 28-30
days and has a regular blood flow for 4-5 days, associated with mild dysmenorrheal.
L.M.P.-17/07/2016 E.D.D.-24/04/2017
5. OBSTETRICAL HISTORY: She is Primi with 29wk with Leaking per vagina with oligohydramnios. She have
one male child of 5 year age. She had one abortion before 2 year.

6. HISTORY OF PRESENT PREGNANCY: 1st TTIMESTER- During her first trimester, she had mild nausea and
vomiting in morning that got relieved on its own. She was given 1 st dose of T.T after one month received
the second dose of T.T.
2nd TRIMESTER- Her ultrasound was done on 20/12/2016. Findings were : SLIVF of 21+5 weeks, placenta
was anterior, Breech presentation. She was advised to take maximum rest at that time.
3rd TRIMESTER- USG done at safdarjung on 12/02/2017, findings were SLIVF, Breech, placenta anterior. AFI
was also checked which comes out to be 1.5 in the largest vertical pocket and 3.5 in total fluid.

7. CHIEF COMPLAINTS OF PRESENT PREGNANCY – Leaking per vagina and severe oligohydramnios.
8. OBJECTIVE DATA: Patient is looking anxious. Abdominal girth is 30 cm and fundal height is less than period
of gestation..

PROGRESS NOTES AND MANAGEMENT AS PER CASE SHEET

DATE POG PULSE B.P. FHS P/A LPV BPV HEART/ ADVICE
LUNGS
21/02/ 30+2W 88/MIN 110/8 146/ Relaxed, pres nil NAD To take rest as
2017 KS 0 MIN breech ent much as possible
MMH
G presentation, Triple antibiotics
22/0 30+3 86/mi 1120 132/ Relaxed, pres nil NAD Maximum fluid
2/20 wks n /80m min breech ent intake.
17 mHg presentation,
23/0 30 + 92/mi 1180 142/ Relaxed, nil nil NAD To monitor daily
2/20 4wks n /78m min breech fetal count &
17 mHg presentation, report if she feels
no movement

TREATMENT GIVEN:
o Sterile vulval pad used
o Triple antibiotic
o Inj Dexa 6mg IM 6hrly x 4doses
o Tab. FS/OC/BC
o w/f FHS and monitor

PHYSICAL EXAMINATION
General Appearance :Normal built, General condition is fair, hydration is adequate, looks tired,
Conscious and oriented.
Head : hair is black in colour, no dandruff/ pediculosis is seen, scalp is seen
Eyes : Conjuctiva-normal, sclera - normal discolouration
Pupils- reacting to the light, no evidence of eye infection
Nose : No septal deviation/ infection/ no blockage in nose
Ear : deafness, no infection/wax, no otitis media
Mouth : Gums- no bleeding, Toungue- dry, No evidence of glossitis/caries/ stomatitis/
tonsilitis
Neck : No evidence of thyroid sweeling and lymph node enlargement
Breast : Soft, secreting colostrums secondary areola visible, nipples are normal, no
Evidence of short/long/inverted nipples.
Chest : Heart sound S1 & S2 is heard, lung sounds are normal and no evidence of
Wheezing or crackles.
Liver and spleen : No evidence of hepatospleenomegaly.
Upper extremitries : normal movement of abduction, adduction and rotation
Abdomen : INSPECTION: Linea nigra and striae visible in lower abdomen, abdominal girth – 30 cm ,
abdomen is relaxed.
PALPATION: Fundal height – 24cm, height of uterus – 27 weeks, uterus is tensed and
shiny, active fetal movements present, fetal parts felt
Auscultation: 146/min
GI system : normal intake of diet, bowel movements are normal, sometimes constipated
Bleeding per Vagina : Nil
Urine output : frequent urination , slightly increased, no burning micturation
Lower extremities : no edema present, no varicose veins seen

INVESTIGATIONS

BOOK PICTURE PATIENT PICTURE

S.no INVESTIG - NORMAL 12/2/17 21/2/17
ATION VALUE
1. Blood group B positive B positive
2. Hb 11-16mg/dl 12.4 mg/dl 9.4 mg/dl
3. TLC 5000=10,000 17100 14200
4. PLT 3lac to 5 lac 2.98 lac 1.32 lac
5. Na 135-145mg/dl 136 mg/dl -
6. K 3.5-4.5 mg/dl 3.5 mg/dl -
7. S. creat 0.6-1.2mg/dl 0.8 mg/dl -
8. RBS 70-110 mg/dl 92 -
9. Blood urea 8-23mg/dl 12mg/dl
10 HIV Negative Negative
11. HBSAG Negative Negative
12. VDRL Non Reactive Non Reactive
URINE –
Protein NIL NIL
Albumin NIL NIL
13. Sugar NIL NIL
14. USG On 11/2/2017 Baby : live intra uterine Baby : live intra uterine
fertilization, 29+6 weeks fertilization, 29+6 weeks
Breech presentation, Breech presentation,
Placenta Anterior Placenta Anterior

15 AFI <2 in largest AFI=1.5 in largest vertical

vertical pocket pocket
16. CRP Negative

ABOUT THE DIAGNOSIS

LPV WITH SEVERE OLIGOHYDRAMNIOS
DEFINITION:
Oligohydramnios is a condition in pregnancy characterized by a deficiency of amniotic fluid to the
extent of less than 200ml at term. sonographically it is termed when the maximum vertical pocket of
liquor is less than 2 cm or when amniotic index is less than 5 cm.

PATHOPHYSIOLOGY OF RH NEGATIVE:
Leaky or Ruptured Amniotic Membranes: Sometimes, the amniotic fluid leaks out through a small tear or hole
in the amniotic membranes, leading to Oligohydramnios. This can occur at any stage of pregnancy but is most
common as one approaches delivery. Fetal Abnormalities: Absence of the kidney or any other kidney
abnormality (renal agenesis, polycystic kidney) in the baby can also hamper urine production

Genetic Factors: Inheriting abnormal genes in an autosomal recessive or autosomal dominant pattern ,the fetal
urine mainly forms the amniotic fluid during the later stages of pregnancy. So, reduction in fetal urine
production due to some pregnancy irregularity, such as obstruction of the fetal urinary tract, can lead to
oligohydramnios

Placental Abruption Placental abnormalities, like a partial abruption, which causes the placenta to peel away
from the inner uterus wall, may lead to amniotic fluid deficiency. Any irregularity in the placental blood and
nutrient supply can prevent the baby from producing urine which may lead to serious complications.

Drug-Induced Causes-Using NSAIDs like indomethacin and certain ACE (angiotensin-converting enzyme)
inhibitors

ETIOLOGY

IN BOOK IN PATIENT
FETAL
 Prom (50%)
 Chromosomal anomalies  PROM since 27/1/2017
 Congenital anomalies
 IUGR
 IUD
 Post term pregnancy
MATERNAL
 Preeclampsia
 APLA syndrome
 Chronic ht
DRUGS
 PG synthetase inhibitors
 ACE inhibitors
PLACENTAL
 Chronic Abruption
 TTTS
 CVS
IDIOPATHIC
CLINICAL FEATURES
IN BOOK IN PATIENT
 Smaller symphysio fundal height  Smaller symphysio fundal
 Fetal malpresentation height = 30 cm
 undue prominence of fetal parts  prominent fetal parts felt
 reduced amount of amniotic fluid  reduced AFI = 3.5 cm
 mother previously pregnant would notice a reduction in
fetal movement

DIAGNOSTIC FINDINGS

IN BOOK IN PATIENT
SYMPTOMS  LPV present
 H/O leaking per vagina  Uterus small for date
 Symptom of preeclampsia present
 Less fetal movements  Breech presentation was
SIGNS: there
 uterus-small for date
 Feels full of fetus
 Malpresentations
 IUGR

USG  AFI = 3.5cms

 AFI < 5 cms (5-8 borderline)
 2D pocket <15sq cms

COMPLICATIONS
IN BOOK IN PATIENT
MATERNAL
 Increased morbidity  Breech presentation was
 Prolonged labour: uterine inertia there
 Increased operative intervention (malformations, distress)
.FETAL
 Abortion
 Prematurity
 IUD
 Deformities: contractures, amputation, pulmonary hypoplasia
 Malpresentations
 Fetal distress
 MSAF
 Low APGAR
MANAGEMENT

IN BOOK IN PATIENT

 Presence of fetal congenital malformation needs delivery

irrespective of the period of gestation.  Sterile vulval pad used
 Isolated oligohydramnios in the third trimester with a normal  Triple antibiotic
fetus may be managed conservatively.  Inj Dexa 6mg IM 6hrly x 4doses
 Oraladministration of water, increases amniotic fluid volume.  Tab. FS/OC/BC
 In labor, cord compression is common.  w/f FHS and monitor
 Amnioinfusion (prophylactic or therapeutic) for meconium  extent delivery upto 37 weeks
liquor is found to improve neonatal outcome.

NURSING MANAGEMENT

ACTUAL PROBLEM LIST (MOTHER)

1. Risk for infection related to PROM

2. Fluid volume deficit related continuous leaking per vagina
3. Knowledge deficit related to disease condition and newborn care.
4. Anxiety related to outcome of pregnancy and health of unborn child
5. Altered nutrition less than requirement related to IUGR
6. Deficient fluid intake, less than requirement related to low amount of liquor
7. Activity intolerance related to low Hb

POTENTIAL PROBLEM LIST

1. Risk for infection related to presence of surgical wound, presence of IV cannula, insertion of indwelling
catheter.
2. Risk for constipation R/T immobility as evidenced by clients verbalizes of the physical discomfort .

NURSING MANAGEMENT

NURSING PROCESS FOR MOTHER:

Nursing diagnosis : fluid volume deficit related to continuous leaking per vagina.

SUBJECTIVE DATA OBJECTIVE DATA

Patient is complaining for weakness and leaking per Patient looks lethargy / AFI of largest pocket was 1.5.
vagina

DESIRED GOAL/ OUTCOME

patients adequate fluid volume will be maintained
 PLANNING IMPLEMENTATION RATIONALE
 Assessment of Examined the skin turgor of mucous To assess the fluid deficit.
hydration status membrane. To asses fluid overload or
 Assessment of -Monitor intake to output chart. deficiency
bleeding
 And output /input -Monitor vital signs. To prevent complication
charting - Advised to take more fluids.

Evaluation: Patient’s skin turgor shows good hydration .

2. Nursing diagnosis : Risk for infection related to PROM

SUBJECTIVE DATA OBJECTIVE DATA

Patient is complaining of leaking per vagina, Patient’s TLC increased to 14,600 on 12/2/2017

DESIRED GOAL/ OUTCOME

: patient will be prevented from infection.

PLANNING IMPLEMENTATION RATIONALE

 Assessment of body
temperature.
 Assessment of discharge
from the vagina for
amount and smell.
 Antibiotics can be start.
 Use sterile vulval pad
 Lab investigations can be
done like CRP and TLC
count.
 Body temperature was assessed.
 Assessment of discharge from the
vagina for amount and smell.
 Triple (metro, ampi and genta)
Antibiotics were started.
 Mother was instructed to use the
sterile vulval pad
 Lab investigations can be done like
CRP and TLC count.
 To check the infection.
 To rule out the UTI.
 To prevent the infection.
 To check the body’s system
to see the immunity of the
patient.

Evaluation: TLC count has been reduced to 11,600 on 15/2/2017

3. Nursing diagnosis : Knowledge deficit related to concern for surgery and fetal well being.

SUBJECTIVE DATA OBJECTIVE DATA

Patient asked so many questions about the disease Patient looks anxious and tensed.
conditions.

DESIRED GOAL/ OUTCOME

to relieve the anxiety and provide information about
disease condition
 PLANNING IMPLEMENTATION
 To provide the mother with  Mother was explained about
health talk in current Oligohydramnios.
condition  She was advised to note the
fetal movements and report
any abnormality
 She was asked to maintain
adequate hydration
 She was informed about the
benefits of left lateral
position
Evaluation: mother verbalized relieved anxiety about her and the infants care.
4. Nursing diagnosis : Anxiety related to outcome of pregnancy and health of unborn child as witnessed by
mother’s frequent doubts about the pregnancy outcome
SUBJECTIVE DATA
Mother verbalizes that her baby is very small and Mother looks anxious and concerned
there is decreased fetal movements
DESIRED GOAL/ OUTCOME
to relieve the anxiety and provide information about
disease condition
PLANNING IMPLEMENTATION
 To alleviate the  Approach and discuss the mother’s
anxiousness of the worry in a calm manner.
mother  -administered in dexamethasone6
 -To clear her doubts mg 6hrly and told her the
about the pregnancy importance of this medine
and the well-being of  -allow her to ask questions and
the fetus clear her doubts
- provide and discuss with her, the
ways to improve the pregnancy
outcome with lots of fluids and
nutritious diet
 -Assure her that the neonate will be
kept in the hospital.
 As she is planned of L.S.C.s.,
importance of the surgery and
preparation of the patient.
 -patient is kept nill per orally before
surgery.
RATIONALE
 To give knowledge to the
mother
 The fetal movement may be
restricted as sometimes
complications develop
 Adequate hydration is
necessary to prevent
further drop in liquor
 To maintain placental
perfusion
OBJECTIVE DATA
RATIONALE
 To alleviate her anxiety
 -So that her doubts are
cleared
 To reduce anxiety related to
disease.
 -nutritious diet can improve
the fetal outcome and
increased fluid intake may
help raise the amniotic fluid
value.
- proper care plays a great
role in the health of IUGR
neonate
- Early information about
hospitalization helps the
mother to cope after birth
of the baby.
- to remove any chances of
aspiration.
Evaluation:
Mother shows less anxiousness about the outcome of labour.
- She verbalizes confidence in caring for her baby.
- She understands the importance of L.s.c.s. and prerequisites before surgery.

5. Nursing diagnosis : Altered nutrition , less than requirement related to IUGR as witnessed by low weight of
mother

SUBJECTIVE DATA OBJECTIVE DATA

Patient verbalizes weight remaining almost the same Mother’s weight is almost stationary, with weight
Wt= 59 kg being 65 kg approx from 6th month onwards to 8th
month

DESIRED GOAL/ OUTCOME

To maintain the adequate nutrition.

PLANNING IMPLEMENTATION RATIONALE

to improve the nutrition of the
mother, in order to improve the
fetal nutritional status
-to improve and achieve an
appropriate maternal weight gain
Advised mother to take small
frequent meals
-Advised her to take plenty of
fluids
-Explained her importance of high
protein and high calcium diet for
fetal growth e.g. all pulses, milk,
soybean, calcium tablets.
- To increase the daily intake of
diet.
- monitored weight and asked to
report weight loss
-adived to keep npo after mid
night and to take light food
before surgery
Small frequent meals are
tolerate better than large meals
- high protein and high calcium
diet is needed to improve the
growth of the fetus
- as weight is not adequate
,daily intake of food should be
increased to attain a reasonable
weight gain
- A decrease in weight should be
reported as it can be due to loss
of amniotic fluid and can be
fatal.

Evaluation: Mother has increased her intake of diet.

- mother has added daily milk intake in her diet.
HEALTH EDUCATION:

IN WARD –
A. Patient is advised to take rest for few days from strenuous activities & also encouraged for early
ambulation.
B. Patient is encouraged to take a well balanced & iron rich diet like pomegranate, jiggery, green leafy
vegetables.
C. She is advised to take her medicines on time and not to skip any dose.
D. She is advised to maintain proper hygiene especially genitals.
1. Treatment :
 Patient was advised take FS/ OC/ BC- till 6 weeks.
 Come for follow up as per unit’s O.P.D
 If any complications like headache, blurring of the vision, foul smelling pad, excessive per vaginal
bleeding.
 Told to report immediately any signs of infection like fever, nausea, vomiting etc.
2. Diet
 Advised mother to take daily protein like egg, milk amd milk products,
 Advised mother to take usual salt but not in excess
 Fluid restriction is not advised
 Advised mother to take energy and iron rich foods like jiggery spinach, green leafy vegetables, Bengal
gram etc.
 Advised mother to avoid unsaturated fats like ghee and butter.
3. Breast feeding
 Advised her to give exclusive breastfeeding for 6 month.
 Told her the importance of breast feed for the baby, mother and the society

PROGRESS NOTES:
Patient improved very well from her condition. She is able to walk with assistance now and also able to do her
self-care activities also. She progressed well from her disease state. Intake output maintained and vitals are
stables. Pain reduced. No signs of infection. She understood how to breast feed and importance of breast feed.
No further complaints.

PROBLEMFACED BY THE PATIENT AND STUDENT

The mother verbalized that there was no one to comfort her in labor room during the labor pains. She was only
given the gown once and no food was given to her. She also said that 2-3 patients are together given one bed.
There is no privacy for antenatal palpation in the ward. There is overcrowding of patient attendants.
Sometimes there is lack of supplies e.g. disposable bed sheet for providing care for the client.

PERSONAL OPINION AND ACHIEVEMENTS.

The case study I took was MOTHER WITH OLIGOHYDRAMNIOS AND IUGR. The care for the mother diagnosed
with OLIGOHYDRAMNIOS AND IUGR is similar in regard to the treatment and there is no complication. Patient
was a registered case in antenatal clinic. Her diagnosis was done at the earliest and treatment given according
to theory. She stood all the treatment. She received adequate medical and nursing assistance and was
recovering well. She was not yet discharged till my posting.

RECOMMENDATIONS
 Each individual experiences of pregnant mother are unique and care is to be provided by keeping that in
mind
BIBLIOGRAPHY
1) D.C.Dutta;“Textbook of Obstetrics”; HiralalKonar; 7th Edition; P 204-206.
2) Myles ; Text Book for Midwives; Churchill Livingston; 15th Edition; P 420-425
3) Dr. G.K. Sandhu, “Obstetric and midwifery” ,lotus; page no 126-130
4) http//www.Google.com
DRUG STUDY
DRUG THERAPEUTIC ACTION
Ferrous sulfate replaces the iron
TAB stores found inn haemoglobin in
Ferrous sulfate red blood cells , myoglobin , and
other haeme enzymes . it allows
tranportaion of oxygen via
haemoglobin.
Tab osteocalcium Calcium supplement
DOSE
Tablet /gems of ferrous sulfate
200 mg O.D /B.D with a glass of
l Avoid intake of milk within 30
emon water for 100 days atleast
Tablet osteocalcium 500 mg p.o
o.d for 6 weeks
NURSING RESPONSIBILITY
Advised to take with lemon water
min before and after taking iron
It will lead to black color of stool
its normal .
If used in syrup form causes
discoloration of teeth.
Must be continued till 100 days .
Never take iron with milk or milk
products.
Assess patients serum calcium
level , so as to get the baseline
data .
Educate to take calcium with milk
Avoid taking iron and calcium
together .
Complete the coursideration as
advise.