Question

Dee is 36 weeks pregnant with her first child. She has come to the L&D unit to be assessed. She complains of bilateral lower pelvic pressure and occasional tightening and relaxing of her abdomen. Her EFM strip reveals a baseline fetal HR of 130 with moderate variability, accelerations 15 beats by 15 beats, and no decelerations. There is only one contraction observed on the monitor in 30 minutes, which was palpated as mild by the RN. The patient denies leaking of fluid or vaginal discharge. During this visit she also complains of increasing heartburn, low back pain, constipation, and difficulty sleeping at night. She would like to know what she can do to get relief from these symptoms.

A). Is the information obtained on the EFM strip reassuring, or non-reassuring, and why?

B). Provide Dee with information explaining round ligament pain and how to differentiate between Braxton Hicks contractions and contractions associated with labor.

C). Describe the nursing management, and if applicable, the possible pharmacological management for each of Dee’s additional complaints.

D). Describe the primary signs of the onset of ‘real’ labor and when she should return to the hospital for further assessment.

Now that Dee is nearing the end of her pregnancy, she has many questions about how to plan for the birth of her baby.

E). What kind of information does she need to consider and include in her birth plan?

Answer 1

A) The information obtained on the Electronic Fetal Monitoring Strip is Reassuring, because:

• Baseline heart rate (130 bpm) is within the reassuring (Category I) range of 110 to 160 bpm
• Baseline fetal heart rate variability is moderate
• Accelerations are present
• Decelerations are absent

For non reassuring pattern, the baseline variability is minimal, marked or absent with bradycardia or tachycardia with variable decelerations or sinusoid pattern. Since, none of these are present in the given EFM strip, it can be interpretated as Reassuring pattern

B). Information about round ligament pain:

• Round ligament pain is common during second trimester and occurs due to expansion of uterus by fetus which leads to ligament stress and pain.
• Patient should be encouraged to take adequate rest and maintain proper body position/ posture to prevent excessive stretching of the ligament
• Round ligament pain can be managed by performing exercises like squats, bringing knees closer to chest
• Application of hot compresses can also relieve round ligament pain

Differences between Braxton Hicks Contractions and Contractions associated with labor:

Braxton Hicks contractions	Contractions associated with labor
Contractions are irregular and weak	Contractions are regular and stronger
Contractions are do not last longer and are apart from each other	Contractions last longer and occurs closely
These contractions are weakened when walking or position is changed	These contractions become stronger with walking or do not weaken even after changing position
These occur above the umbilicus or at the back	These occur in the lower part of the abdomen
No changes in cervix on examination	Cervix shows softening, effacement, dilation with blood
Cervix moves to posterior position	Cervix moves to anterior position
Fetus presenting part is not engaged in pelvis	Fetus presenting part is engaged in pelvis

C). Additional complaints - Nursing management and pharmacological management:

Complaint	Nursing management	Pharmacological management
Heartburn	i. Educating the client to avoid fatty foods or large meals ii. Encouraging the client to maintain good posture to avoid regurgitation of gastric contents due to enlarging uterus iii. Encouraging hot milk, herbal tea for symptomatic relief	Calcium containing Antacids, Simethicone to be administered between the meals
Low back pain	i. Encouraging the client to take adequate bed rest ii. Teaching the client about good body mechanics iii. Application of heat iv. Encouraging the client to perform exercises like squatting	Analgesics such as paracetamol may be required for intense pain. Ibuprofen, Naproxen may be used upto second trimester but should not be used in third trimester
Constipation	i. Encouraging adequate hydration with 6-8 glasses of water ii. Promoting the intake of dietary fiber iii. Maintaining regular exercise schedule iv. Encouraging regular and timely bowel pattern v. Teaching breathing and relaxation technqiues	Stool softeners like Docussate sodium, or laxatives like Bisacodyl can be used. However, mineral oil or enemas and other laxatives are contraindicated without physician advice
Difficulty sleeping at night	i. Teaching conscious relaxation techniques ii. Encouraging taking warm milk or warm shower before sleep iii. Non pharmacological interventions such as massage, effleurage iv. Institution of comfort measures like adequate pillow support, good sleep hygeine, warm and pleasant environment	Pharmacological interventions are reserved only for extreme sleep disturbances as most of the hypnotics and sedatives are teratogenic. However, Zopidem can be used in severe insomnia

D). Following are the primary signs of the onset of real labor which indicates the client that she shoud return to the hospital for further assessment:

• Uterine contractions occur regularly with more duration and stronger in nature
• Comfort measures, walking or changing position does not relieve contractions and even becomes intense
• A pain in the lower abdomen which continues with increasing contractions
• Cervical changes like softened cervix, effacement, cervical dilation (above 3 cm)
• Increased urinary frequency due to presenting fetus
• Fetus is engaged in pelvis
• Rupture of seepage of fluid

E). Information that needs to be considered and included in the birth plan of the client:

• Food and fluid preferences and intake documentation
• Details about the preferred companions to be accompanied during labor
• Type of dressing to be worn and need of any personal preferences such as music, lighting, privacy etc
• Additional need of interpreters in case of racial or language differences
• Information regarding transportation, comfortable birth position, need of birth balls, seitz baths, shower baths etc
• Comfort and relaxation techniques
• Pharmacological and non pharmacological measures used during labor process
• Education about intravenous medications used during labor, induction of labor
• Cultural and religious preferences regarding the care of newborn, mother, placenta etc