Obstetrics Nursing Essay

What is the definition of an “acceleration” on a FHR strip? What does this indicate for the nurse? With references

Review of literature is an essential component of research study as it provides a broad understanding of the research problem. A review of related literature involves the systematic identification, location, scrutiny and summary of written materials that contain information on research problem (Polit and Hungler, 1998). Keeping this in mind, the investigator studied and analyzed into the accessible sources and gained in-depth understanding from the related studies about the first aid management of obstetrical emergencies.Obstetrics Nursing Essay

ORDER  HERE A PLAGIARISM-FREE PAPER HERE

The role of midwife is unique in the care and treatment of a mother and child. Throughout the birth process; the role is comprehensive and involves education treatment and collaboration with a more skilled medical team. The estimate of mortality due to poor delivery practices was over 110 maternal deaths/100,000 live births. About 40 -60 % of death of women aged 15- 34 years were attributed to pregnancy and childbirth. The medical complications precipitating death, haemorrhage, hypertension and infection were also major causes of mortality related to abortion. The midwife must be prepared for all emergencies, including medical factors such as obstetric complications, referral problems such as transportation, inadequacies, and belief factors such as fear of hospitals. Risk can be reduced by frequent consultations with health workers during pregnancy, using trained attendant at every birth, being aware of danger signs, spacing pregnancies over two years apart, avoiding pregnancies at young or old ages, maintaining proper nutrition and work load, and involving midwifes at all levels of care. – Kebe. Y(2000)Obstetrics Nursing Essay

STUDIES RELATED TO OBSTETRICAL EMERGENCIES
Obi SN, Ozumba BC..et.al (2001), conducted a retrospective study to identify the factors of unbooked obstetric emergency cases which increases the maternal mortality at University of Nigeria Teaching Hospital, Nigeria. The study concludes that lack of basic education and poverty are the major identifiable risk factors. Improving health care facilities, female education and regular training courses of medical personnels will help to reduce the maternal mortality.

Ray.A. M, Salihu. H.(2004) conducted a study to review the results of 15 Traditional birth attendants(TBA) and midwife based interventions that aim to improve skilled assistance in delivery and recognition and referral of complications. Outcome measures used to evaluate the impact of the programmes varied. Five of the five programmes reviewed that evaluated the impact on maternal mortality demonstrated decline in maternal mortality ratios. Two of three studies measuring morbidity related indicators found improvement of some but not all morbidity outcomes. Six of seven showed a trend of improved referral rates. Three of three found high levels of knowledge retention among trained TBAs. Programmes with the greatest impact utilised TBAs and village midwives with multisectorial interventions. These findings suggest that TBAs and village midwives contribute to positive programme outcomes.Obstetrics Nursing Essay

Sharon Maslovit, Gad Barkai(2004) conducted a study to assess the effectiveness of simulation based training programme among midwives and obstetricians in Israeli Center for Medical Simulation, United Kingdom. One hundred and sixty five samples were selected by random method. Among the samples 77 were obstetricians and 88 were midwives. Questionnaire responses showed that post-test score (79.4 ± 4.3) were more than pre-test score (70 ± 5.3). The study concluded that employing high fidelity simulations of obstetrical emergencies has great teaching and learning potential and simulation can provide a learning experience that facilitates knowledge application to midwifery practice.

Kildea S, Kruske S, Bowell L (2006), conducted a descriptive study to improve the maternity emergency skills and knowledge of health service providers, without midwifery qualification at Institute of Advanced Studies, Charles Darvin University, Northern Territory Australia. The samples were given multidisciplinary short course aimed at improving knowledge and skills in detection, management and referral of obstetrical emergencies. The study concluded that the course was an effective strategy to improve the maternity services offered to women in remote Australia.Obstetrics Nursing Essay

Draycott.T, Sibanda.T…et.al (2006), conducted a cohort observational study to evaluate whether obstetrical emergency care improves the neonatal outcomes. The samples are the term, cephalic presenting singleton infant. The study reveals that the infants born with 5-minute Apgar scores of

Crofts. Eills…et.al (2007), conducted a study to assess the effectiveness of obstetric emergency training programme on knowledge regarding obstetric emergencies among medical graduates in Bristol Medical Simulation Centre, England. The result of the study showed significant difference between pre-test and post-test. Post-test score was (23.1) more while comparing to pre-test score (18.1) and p< 0.001.Obstetrics Nursing Essay

Prem Kumar (2009), conducted a study to evaluate the risk factors and management of maternal and perinatal outcome of uterine rupture was conducted in Department of Obstetrics and Gynaecology, JIPMER, Pondicherry. Two fifty three case of uterine rupture was managed in 10 years. The result showed that 128 cases (50.8%) of uterine rupture occurred in a scarred uterus and 125 (49.40%) occurred in unscarred uterus. The predisposing factors include cephalopelvic disproportion in 69 cases (27.25%), malpresentation in 20 (7.90%) cases, labour induction in 14 cases (11.64%) and multiparity in 20 cases (7.90%). Repair of uterus was done in 147 cases (58.33%) and hysterectomy in 105 cases (41.51%). The study concluded that there were 7 maternal deaths (2.76%) and perinatal mortality was 94.07%. This study reveals that the warning of the impending complications was not detected and treated in time.

Partamin, Kim..et.al (2010), conducted a study to assess knowledge and performance of skilled birth attendants providing emergency obstetric and newborn care in Afghanistan. Midwives and doctors scored similarly in assessments of decision making and performance of technical skills. Skilled birth attendants showed weakness in specific steps to manage common high risk emergencies. The study concludes that midwives and doctors in Afghanistan are similarly competent. In-service training and job rotation could help skilled birth attendants retain their emergency obstetric care skills.Obstetrics Nursing Essay

Sabitha Nayak(2011) – to assess the knowledge on first aid measures of obstetrical emergencies among health members in Natekal PHC(Mangalore). The study finding revealed that majority of the samples 55% were in the age group of 25-30 years and 39 % received information from the teaching programs, 20% from mass media 13% from friends and 17% of them do not have exposure to any source of information about the first aid practices. The results showed that majority of the samples 62% had good knowledge, and 38% had average knowledge about the first aid practice. There is significant association between knowledge and demographic variables like age, educational status, and no significant association with membership in any social organisation, occupation and place of living.

Puri R, Rulisa S.et.al (2012), conducted a study to determine the knowledge, attitude and practice of obstetric care providers in Bugesera District, Rwanda. The study captured 87% of obstetric care provider, most expressed a need to improve their knowledge (60.6%) and skill confidence (72.2%) in safe motherhood. The mean percentage of correct answers for 50 questions assessing overall knowledge was 46.6%, in which 39.3% was correct on normal labour and 37.1% was correct on obstetrical complications. The study had identified that there was a need to improve safe motherhood knowledge and practices of obstetric care providers.Obstetrics Nursing Essay

Ameh C, Hofman J..et.al (2012), conducted a study to assess the impact of emergency obstetric care training in Somaliland, Somalia. The study result showed that healthcare providers reacted positively to the training, with a significant improvement in 50% of knowledge and 100% of skills. The study concludes that the training impacted positively on the availability and quality of emergency obstetric care and resulted in “up skilling” of midwives.

OB/GYN Nurse There are many types of nursing careers you can decide to take, the type of nursing career I chose is an OB/GYN nurse. OB/GYN is used as an abbreviation for the actual name of this career. The “OB” is short for obstetrics or for an obstetrician, which is a physician who specializes in delivering babies. “GYN” is short for gynecology or for gynecologist, which is a physician who specializes in treating diseases which develop in the female reproductive system. Therefore an OB/GYN Nurse is a type of nurse who helps deliver babies and which also helps treat diseases of the female reproductive system. An OB/GYN nurse can be in the delivery room helping out the doctor when the baby is born, or the nurse can also, while the patient is pregnant, take vital signs and do ultrasounds. OB/GYN nurses help women during pregnancy, labor, and childbirth. They also help women with health issues in their reproductive system.Obstetrics Nursing Essay

The above studies reveal that midwives do lack knowledge on obstetrical emergencies and based on their knowledge training programmes are recommended to improve their level of knowledge to practice effective care during obstetrical emergencies. From these studies the investigator gained in-depth knowledge and thus it helped in discussion and comparing the level of knowledge of the midwives with the present study.

Madam NTR is a 34 years old Malay lady with gravida 4 and parity 3, currently at 37 weeks of gestations. She was admitted on 21st Nov 2010 at gestational age of 30 weeks and 1 day, due to referral from Health Clinic Sendayan in view of placenta previa based on ultrasound findings during a routine antenatal visit. Her estimated date of delivery was on 20th Jan 2011. She was asymptomatic with no complaints of per vaginal bleeding, contraction pain, leaking liquor or show. Fetal movements were felt and were not reduced. She has no history of placenta previa in her previous pregnancies.Obstetrics Nursing Essay

The first day of her last normal menstrual period was on 15th Apr 2010. This was an unexpected pregnancy but both her and her husband wanted it. She suspected she was pregnant when she missed her menses for 4 weeks. She confirmed her pregnancy after urine pregnancy test done in a private clinic yielded positive result. Booking was done in Maternal and Child Health Clinic Gadong at 16 weeks of gestation and the dating scan at 16 weeks revealed parameters corresponding to date. However, placenta was noted to be low lying during that scan. Throughout her routine antenatal visits, she was normotensive, not anaemic and did not have diabetes mellitus. HIV and VDRL test were negative. Her blood group type is O Rh D positive.Obstetrics Nursing Essay

This is her fourth pregnancy. Her third pregnancy was in the year of 2007. She delivered a full term baby boy with birth weight of 2.6 kg via caesarean delivery due to breech presentation in Hospital Tuanku Jaafar Seremban. She delivered her first two children who are both males in the year of 2004 and 2005 via spontaneous vaginal delivery, with birth weight of 4.26kg and 2.6kg respectively. There was no history of shoulder dystocia. All her children were born alive and well. Antenatal, natal and postnatal for all previous pregnancies were uneventful.

She attained menarche at the age of 12. It is regular at 28 to 30 days cycle with duration of 5 to 7 days. There was neither dysmenorrhea nor menorrhagia. She practised coitus interuptus as contraceptive measure. She never had any PAP smear done previously.

Past surgical, medical and drug history were unremarkable. Family history was unremarkable. She and her husband are married for 7 years. They are staying together with their three children in Gadong Jaya Village. She is a housewife. She neither smokes nor drinks alcohol. On the other hand, her husband works as a construction worker. He is a smoker but not alcoholic. Family income is approximately RM2000 per month which is barely adequate for their living.Obstetrics Nursing Essay

Physical examination:
Madam NTR was alert, conscious and communicative. She was not in pain or respiratory distress. Her height and weight are 165cm and 76kg respectively. Her blood pressure was 110/80 mmHg; pulse rate was 86 beats per minute of regular rhythm and strong volume; temperature was 37° C; respiratory rate was 19 breaths per minute. All vital signs were within normal range. Upon general examination, there was no conjunctival pallor, sclera jaundice, palmar erythema or peripheral cyanosis. Thyroid glands were not palpable and breast examination was unremarkable. There was bilateral pedal edema up to mid-shin. Cardiopulmonary examination was unremarkable.Obstetrics Nursing Essay

Upon examination of the abdomen, it was distended with a gravid uterus. Linea nigra and striae gravidarum were visible. There was a tranverse scar, measuring 12cm, located above pubic symphysis. Distension appeared to be corresponding to gestational age. The umbilicus was flattened. On light palpation, the abdomen was soft and non-tender. Uterus was not irritable. Symphysiofundal height was 38 cm which was corresponding to gestational age. It was a singleton pregnancy with transverse lie and cephalic presentation. The liquor was adequate. Estimated fetal weight was 3.0-3.2kg. Fetal heart sound was 160 beats per minute.

Investigations
Full Blood Count revealed normal haemoglobin level (10.9g/dL).Obstetrics Nursing Essay

Transabdominal Sonography(TAS) revealed transverse lie fetus with the presence of fetal activity, estimated fetal weight of 3.19kg at 37 weeks of gestation, anterior placenta previa type 3 (placenta previa major) with evidence of placenta accreta at one area over bladder base. The images also demonstrated placental lacunae, gross increase in vascularity of cervix which is suggestive of placenta accreta.

Diagnosis
Anterior placenta previa type 3 with possible placenta accreta.Obstetrics Nursing Essay

Management
Upon admission, Madam NTR’s vital signs were taken. Cannula was inserted and blood was taken for full blood count investigation and blood group cross-matching. Madam NTR was also given the explanation to keep her in ward until delivery and the condition of her pregnancy. She was encouraged to rest in bed and decrease activity level to avoid bleeding. Ultrasound was performed to confirm the diagnosis of placenta previa.

She was then monitored for any contractions or bleeding. Madam NTR’s pad chart, fetal kick chart and labour pregnancy chart were strictly monitored. Fetal heart rate was assessed 4 hourly with Daptone. Cardiotocography was done regularly and it was normal. She was given a course of IM dexamethasone 12mg BD of 1 day duration at 30 weeks of gestation. Full blood count investigation was performed once weekly and transabdominal sonography was carried out once in every 2 weeks throughout admission. Anemia should be corrected if present.Obstetrics Nursing Essay

ORDER  HERE NOW

Madam NTR was also prescribed ferrous fumarate, folic acid, vitamin B complex as well as ascorbic acid. She was eventually planned for an elective caesarean delivery on 5th Jan 2011 at 37 weeks of gestational age. Prior to that, she was counseled about risk of haemorrhage and possibility of hysterectomy to be done during operation as well as option of conservative management etc. Written informed consent was taken from both her husband and her.

Progression
Throughout the admission, she was comfortable and her vital signs were all normal. She had no any episodes of vaginal bleed, leaking liquor, show, uterine contraction and pain. She was not anaemic as evidenced by normal values of her haemoglobin levels. The most recent haemoglobin value was 10.9g/dl. Fetal well-being was assured as evidenced by normal CTG results. She and her fetus remained stable until the scheduled operation date.Obstetrics Nursing Essay

A day prior to that, she was kept nil by mouth. Packed cell blood was ready for transfusion if needed. After delivery of the fetus, manual removal of the placenta was done and placenta accreta was found to be at the anterior bed of lower segment of the uterus. She developed a massive uterine haemorrhage and a hysterectomy was performed. 3 units of packed cells (1 litre in total) were transfused intraoperatively. The operation lasted for 1 hour and 15 minutes.

Find out how NursingAnswers.net can help you!
Our nursing and healthcare experts are ready and waiting to assist with any writing project you may have, from simple essay plans, through to full nursing dissertations.

She delivered a baby boy weighs 3.2kg with Apgar score of 6 at first minute and 9 at fifth minute of life. After being assessed by paediatrician, he was discharged to the mother. Estimated blood loss was 2.8 litres. Explanation about intraoperative findings and the decision of attending doctor to proceed to hysterectomy was given to Madam NTR. Postoperatively, she remained hemodynamically stable. Post operative haemoglobin level was 12g/dl. She was able to ambulate and tolerate orally on third day after operation despite minimal pain over operation site. She did not complain of shortness of breath, palpitation, chest pain or calf pain.Obstetrics Nursing Essay

Baby was pink, active and well with no jaundice. Breastfeeding was established. Both of the mother and baby were discharged on 7th Jan 2011and subsequent follow-up was scheduled to be 2 months later. She should be arranged for psychological review and management as termination of fertility can sometimes cause devastating psychological impact to women.Obstetrics Nursing Essay

Discussion
What other alternatives that Madam NTR has other than hysterectomy in the case of placenta accreta? Is hysterectomy absolutely indicated in Madam NTR?
Mainstay traditional management has centred upon hysterectomy which has a high complication rate and terminates fertility of a woman. It can also cause devastating psychological consequences. While in vast majority of cases hysterectomy will remain appropriate, there are other management options available involving conservative approaches. The main nonsurgical conservative management would be to leave the placenta undisturbed in situ for it to be resorbed or to be passed spontaneously. It is expected that bleeding will remain minimal with this approach. This enables fertility to be preserved even though leaving the placenta in situ has implications for infection and recurrence.Obstetrics Nursing Essay

Loïc Sentilhes et al.(1) concludes that successful conservative management for placenta accreta does not compromise the patients’ subsequent fertility or obstetrical outcome but there is a high risk that placenta accreta may recur during future pregnancies. Florence Bretelle et al.(2) conducted a retrospective study in which 50 cases of placenta accreta were studied and 26 patients (52%) were treated conservatively. 21 of them (80.7%) did not undergo hysterectomy and 3 women had successful pregnancy during follow-up. This further proves that treated patient with placenta accreta selectively with conservative approach enables fertility to be preserved without increasing morbidity.Obstetrics Nursing Essay

However, conservative approach is usually considered only when bleeding is minimal. In this case of Madam NTR, there was severe haemorrhage encountered after delivery of fetus. Conservative management such as leaving the placenta in situ will lead to severe postpartum hemorrhage or even maternal death. Uterine compression suturing to stop the bleeding was not able to be performed as her uterus was too fragile to hold the sutures. Therefore, hysterectomy is absolutely indicated in the case of Madam NTR for her safety. This is her fourth pregnancy; therefore termination of fertility is not a major concern in her as discussed previously prior to obtaining her consent.Obstetrics Nursing Essay

As Madam NTR was planned for a high risk surgery with possibility of hysterectomy, counseling and obtaining written informed consent prior to surgery play a vital role. After being counseled, Madam NTR stated that she had little understanding about her situation and the surgery but not to the full understanding due to inability to fully comprehend medical terminologies used. The question here would be: “Has the attending doctor done his duties well enough and is patient’s autonomy protected in this context?”
Informed consent is the core principle of modern medical practice. The primary aim of the consent process is to protect patient’s autonomy. Patients have the right to refuse medical care, even when it means they will die. This surgery is associated with high complication rate, termination of fertility and devastating psychological consequences to patient. Therefore, educating and informing her about her healthcare options, advantages and disadvantages associated with recommended management as well as other alternatives are very crucial.Obstetrics Nursing Essay

The point is not merely to disclose information, but to ensure patient’s comprehension of relevant information. Unfortunately, very often that doctor are disclosing information presuming that patients with different level of maturity, education level, cultural background and native language will be able to comprehend. On top of that, doctors are so used to medical terminologies and it is often found difficult to disclose medical information in layman’s terminologies. Majority of patients whom I encounter were not aggressive in seeking opportunities to raise questions to attending doctors, especially during ward round whereby patient will be surrounded by specialist accompanied by medical officers, housemen and medical students. All these further jeopardize patient’s autonomy to exercise personal choice with total comprehension of relevant medical issues.

In the case of Madam NTR, she and her husband should first of all be told what a placenta is before explaining to them about placenta praevia. Subsequently, attending doctor should explain to her the reason vaginal delivery was not able to be carried out as the placenta covers the entrance to the womb (cervix) entirely, which is known as major placenta praevia. Therefore, caesarean delivery is absolutely indicated and it will be conducted by experienced obstetrician and anaesthetist on duty. If an emergency arises, a consultant will be present.Obstetrics Nursing Essay

Risk of severe bleeding from placenta praevia which can put the life of the mother and baby in danger should be emphasized; therefore explaining the purpose of blood group cross- matching for blood transfusion. She should also be informed that rarely, placenta praevia may be complicated by a problem known as placenta accreta, when the placenta is abnormally attached to the womb, making separation at the time of birth difficult. Most of the time, it will pass out spontaneously. However, if the bleeding continues and cannot be controlled, removing the womb has to be done to control the bleeding after consideration of conservative approaches such as leaving it in situ with possibility of recurrence or infection fails.Obstetrics Nursing Essay

She has to be told to fast prior to operation. Choices of analgesia should be discussed with anesthesiologist in relation to risks and advantages for each option. Lastly and most importantly is to assure her that the healthcare team will recommend the best way for both her and her baby and at the same time, she has the right to be fully informed about her health care and to share in making decisions about it.

Under the law, the doctor has a duty of medical care to give ‘adequate’ information about the proposed medical treatment. The breach of informed consent in today’s legal setting is more commonly interpreted as negligence when the doctor has not disclosed the risk of procedure and when the risk occurs, causing harm to patient. In the English case of Wells v Surrey Area Health Authority (3), a 36-year-old woman with 2 children, was advised to proceed to caesarean delivery after prolonged labour. She was in exhausted state when she was suggested to be sterilized during the surgery and consent was signed and sterilization was done. When she recovered, she complained that consent was invalid as it was taken when she was mentally confused. She sued the doctor for assault and battery for operation was done without consent as well as for negligence as information regarding sterilization was not given at all.Obstetrics Nursing Essay

In conclusion, informed consent should be practiced in the correct way, especially in obstetrics and gynaecology, an area with high risk of medico-legal perspectives, to provide best treatment and management to patient and fetus as well as protecting doctors from being sued for negligence. Obstetrics Nursing Essay