IV.

ANATOMY AND PHYSIOLOGY

I. GENERAL OBJECTIVES:

The purpose of this study is to present general picture of through effective nurse-
patient interaction and relevant researches with critical, component, and collaborative
application of the nursing process.

SPECIFIC OBJECTIVES:

To obtain pertinent information about the patients demographic and socio profile.
To educate ourselves about the pathophysiology of its pathogenesis, causes and its clinical
manifestation.
To identify the medical and surgical management indicated for the patient.
To establish appropriate nursing care plan that includes the dependent and independent and
collaborative nursing.
To formulate necessary discharge planning and health teachings essential for the patients
fast recovery and prevention of possible complication.

II. PATIENTS PROFILE

Name: Leica Malicdem

Sex: Female
Civil status: Married
Address: Baybay Polong Binmaley
Birth date: Feb. 25, 1985
Age: 25 yrs.old
Birth Place: Binmaley
Nationality: Filipino
Religion: Roman Catholic

 PAST AND PRESENT HISTORY

A case of 25 years old female, Roman catholic and is currently residing at Baybay
Polong, Binmaley. She is a degree holder and currently unemployed patient claimed that she had
complete vaccines based on EPI and also claimed that on her father side they have a history of
hypertension while on mother side they have family history of diabetes and heart disease. She had
her first menstruation @ 15 years old and can consume 2 pads per day, last at 3-5 days. It was her
first confinement for this year. She had a history of dengue fever when she was 7 years old.
III. DISEASE ENTITY

A. INTRAUTERINE FETAL DEATH

Fetal death in utero (stillbirth) is defined in most states as a demise at ≥20 weeks of
gestation and/or weight of ≥500 grams. The fetal death rate in the United States varies among races,
but overall it is 6.8/1,000 total births and accounts for approximately half the perinatal mortality
(fetal and neonatal deaths). Management of fetal death in utero has changed dramatically from
earlier recommendations that regarded the event as a medically innocuous condition to be managed
conservatively except under life-threatening circumstances, with 75% of women delivered within 2
weeks after fetal demise. After coagulopathy was observed in pregnancies complicated by fetal death
in utero and with newer agents to effect cervical ripening and uterine contractions, the management
of stillbirth has become more proactive.

C. DIAGNOSIS OF FETAL DEATH

History and physical examination are of limited value in the diagnosis of fetal death. In most
patients, the only symptom is decreased fetal movement. An inability to obtain fetal heart tones
upon examination suggests fetal demise; however, this is not diagnostic and death must be
confirmed by ultrasonographic examination.

Fetal demise is diagnosed by visualization of the fetal heart and the absence of cardiac activity.

C. MANAGEMENT of FETAL DEATH

Once the diagnosis of fetal demise has been confirmed, the patient should be informed of
her condition. Often, allowing the mother to see the lack of cardiac activity helps her to accept the
diagnosis. Labor induction should be offered after diagnosis. Patient responses vary in regard to this
recommendation; some wish to begin induction immediately, while others wish to delay induction
for a period of hours or days until they are emotionally prepared.

When a dead fetus has been in utero for 3-4 weeks, fibrinogen levels may drop, leading to a
coagulopathy. This is rarely a problem because of earlier recognition and induction. In some cases of
twin pregnancies, induction after the death of a twin may be delayed to allow the viable twin to
mature.
 Induction may be accomplished with preinduction cervical ripening followed by intravenous
oxytocin (see Cervical Ripening). Patients with a history of a prior cesarean delivery should be treated
cautiously because of the risk of uterine rupture, just as in any birth following cesarean delivery.

Early fetal demise may be managed with laminaria insertion followed by dilatation and
evacuation. In women with fetal death before 28 weeks' gestation, induction may be accomplished
using prostaglandin E2 vaginal suppositories (10-20 mg q4-6h), misoprostol (ie, prostaglandin E1)
vaginally or orally (400 mcg q4-6h), and/or oxytocin (preferred in women with prior uterine surgery).
In women with fetal death after 28 weeks' gestation, lower doses should be used.

The American College of Obstetricians and Gynecologists (ACOG) guidelines for induction of
labor states that prostaglandin E2 and misoprostol should not be used in women with a history of a
prior uterine incision because of the risk of uterine rupture. In 2003, Dickinson and Evans reported on
the efficacy of oral, vaginal, and combined administration of misoprostol for second-trimester
induction in women without a uterine scar and found that the superior regimen was misoprostol at
400 mcg vaginally every 6 hours. A meta-analysis of the use of misoprostol for induction in the
second and third trimester showed efficacy of multiple routes (vaginal, oral, sublingual), frequencies
(every 3-12 h), and dosages (100-400 mcg).
Pain management in patients undergoing induction of labor for fetal demise is usually easier
to manage than in patients with live fetuses. Higher doses of narcotics are available to the patient
and often a morphine or Dilaudid PCA is sufficient for successful pain control. Should a patient desire
superior pain control to intravenous narcotics, epidural anesthesia should be offered.

D. CAUSES of FETAL DEATH

The etiology of fetal demise is unknown in 25-60% of all cases. In cases where a cause is
clearly identified, the cause of fetal death can be attributable to fetal, maternal, or placental
pathology. One prospective study attributed 64.9% of fetal death to placental pathology overall. The
same study noted higher rates of fetal demise secondary to placental pathology at late gestational
age.

Maternal
•Prolonged pregnancy (>42 wk)
•Diabetes (poorly controlled)
•Systemic lupus erythematosus
•Antiphospholipid syndrome
•Infection
•Hypertension
•Preeclampsia
•Eclampsia
•Hemoglobinopathy
•Advanced maternal age
•Rh disease
•Uterine rupture
•Maternal trauma or death
•Inherited thrombophilias

Fetal
•Multiple gestations
•Intrauterine growth restriction
•Congenital abnormality
•Genetic abnormality
•Infection (ie, parvovirus B19, CMV, listeria)
•Hydrops
Placental

•Cord accident
•Abruption
•Premature rupture of membranes
•Vasa previa
•Fetomaternal hemorrhage
•Placental insufficiency
Risk factors (weak predictive value)
•African American race
•Advanced maternal age
•History of fetal demise
•Maternal infertility
•History of small for gestational age infant
•Small for gestational age infant
•Obesity
•Paternal age
Placental
•Cord accident
•Abruption
•Premature rupture of membranes
•Vasa previa
•Fetomaternal hemorrhage
•Placental insufficiency
Risk factors (weak predictive value)
•African American race
•Advanced maternal age
•History of fetal demise
•Maternal infertility
•History of small for gestational age infant
•Small for gestational age infant
•Obesity
•Paternal age

E. FREQUENCY of FETAL DEATH

In 2005, data from the National Vital Statistics Report showed a US national average stillbirth
rate of 6.2 per 1000 births.1 Worldwide, this rate varies considerably depending on the quality of
medical care available in the country in question and the definitions used for classifying fetal
deaths. Underreporting in developing nations is common, which makes comparisons even more
difficult.

F.SIGN AND SYMPTOMS

Certain signs and symptoms make a healthcare provider suspect a possible stillbirth. These
include:
a mother who notices the baby has stopped moving for a long period of time
a uterus or womb that fails to get bigger over time
an inability to hear the baby's heartbeat with a special heart monitor
lack of movement of the baby or no heartbeat during a pregnancy ultrasound, a special test
that uses sound waves to show the baby
an abnormal blood level of the hormone of pregnancy, known as a quantitative HCG test

OVERVIEW
VI. DOCTOR’S ORDER
07-14-10 VERBAL ORDER
7 PM Monitor vital sign every 2 hours
Pls. do internal examination if with contraction and abdominal pain
07-15-10 VERBAL ORDER
2 AM IVF to follow : D5LR 1 x 15 gtts/min
7:30 AM Soft diet
8:20 AM for IE now and refer
Monitor contraction
Misoprostal ¼ tab, intrvaginally
4:30 PM V.O for delivery of fetus
Transfer to OR
07-16-10
DAT when fully awake
Incorporate oxytocin to remaining 250cc of IVF to unit @ 30gtts/min
Watch out for profuse vaginal bleeding and refer
Monitor vital signs every 15mins to stable