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Postnatal Care and Prematurity Management Case Study

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Updated: Jun 25th, 2022

Introduction

Despite the current state of hospital medicine, difficult pregnancies are not uncommon today. For any healthcare specialist, it is critical to sort out priorities when it comes to patients’ needs in complex cases. This paper delves into the topics of postnatal care and prematurity management and explores the case of Shanvi, a woman with multiple health issues and her newborn son. The essay is devoted to a few subtopics, including risk factors present in the case, care interventions needed to manage the premature baby, and Shanvi’s postnatal care needs. Overall, the patients’ needs include proper nutrition and dietary habits, constant monitoring of health, and timely education.

Risk Factors Contributing to Adverse Perinatal Outcomes

Before being born, the fetus uses the resources of the mother’s body to sustain life and develop properly. Pregnancy is a huge stress for any woman, and there is a variety of health issues that manifest themselves or intensify during this period and are associated with the risks of adverse perinatal outcomes. Based on Shanvi’s pregnancy and psychosocial history, it is possible to single out a number of factors that increase the likelihood of unwanted health outcomes for the parturient woman and the fetus.

Four factors that are present in the case include abnormal BMI levels (33.4), the diagnosis of gestational diabetes, the history of lower segment Cesarean section resulting in neonatal death, and the experience of domestic violence. The factors are considerably different in terms of the way that they predict complications and risks during and after delivery.

Gestational Diabetes and Perinatal Heath

Gestational diabetes belongs to the number of harmful conditions that develop in pregnant women. It affects up to fifteen per cent of pregnant non-diabetic patients and is manifested in a rapid increase in blood sugar levels (Billionnet et al., 2017). The diagnosis of gestational diabetes significantly increases the risks to give a preterm birth or have indications for Cesarean section (Billionnet et al., 2017). Also, compared to non-diabetic women, pregnant patients with this condition are statistically more likely to develop eclampsia manifested in high blood pressure, headaches, and decreased urination (Billionnet et al., 2017).

In general, according to a large cohort study conducted by Billionnet et al. (2017), the diagnosis of gestational diabetes is associated with higher odds of developing almost any type of unwanted perinatal outcomes. The only exceptions that the researcher’s lists are the malformations of the newborn’s central nervous system and perinatal death – the risks of these conditions in diabetic and non-diabetic parturient women are not drastically different (Billionnet et al., 2017). Nowadays, the impact of gestational diabetes on mortality rates in neonates who are less than seven days old remains a controversial question due to the presence of mixed findings.

Importantly, the extent to which gestational diabetes impacts perinatal health is also linked to the selection of treatment strategies. For instance, women with this condition that receive insulin treatment are more likely to give birth to children who develop infantile respiratory distress syndrome compared to diet-treated patients (Billionnet et al., 2017). Actually, the majority of adverse events peculiar to perinatal health are more likely to occur in insulin-treated populations with gestational diabetes (Billionnet et al., 2017). Based on that, when evaluating health risks for pregnant women with this diagnosis, it is critical to make allowances for the selected treatment option.

Gestational diabetes impacts perinatal health in a negative manner, but the size of its adverse effects is strongly dependent on the correctness and timeliness of decisions regarding treatment. If the condition is not diagnosed on time and left untreated or poorly treated, the fetus is more likely to experience abnormal growth or develop hypoglycemia right after birth (Hope, Ifeanyi, & Braxton, 2019). Moreover, when it comes to gestational diabetes, improper medical treatment often results in the development of neonatal jaundice (Hope et al., 2019).

Jaundice is extremely dangerous in newborns since it involves the risks of bilirubin-induced death or can contribute to neurodevelopmental disorders that manifest themselves as the child grows up (Olusanya, Teeple, & Kassebaum, 2018). It is also known that the children of women with improperly treated gestational diabetes are among the risk groups for gaining excess weight and developing type 2 diabetes (Hope et al., 2019). Also, if no treatment is provided at all, the risks of having a stillbirth multiply (Hope et al., 2019). Thus, timely and appropriate treatment is required to minimise perinatal health risks associated with gestational diabetes.

High Maternal BMI and Perinatal Health

Any woman’s body weight impacts her ability to engage in a variety of physical activities, thus affecting almost any aspect of life. In the gestational period, body weight increases naturally, but it is critical to monitor BMI levels to evaluate risks accurately. At 12 weeks of pregnancy, Shanvi’s BMI index already exceeded 33, which indicates the presence of moderate obesity. Obesity before and during pregnancy is often cited as one of the most common factors that increase health risks. For instance, compared to expecting mothers with BMI levels ranging from 18.5 to 25, obese pregnant women are almost three times more likely to give birth by Cesarean section (Phillips, Skelly, King, Bernstein, & Higgins, 2017). In addition, stillbirths occur in obese women sixty per cent more often than in patients with normal BMI levels (Phillips et al., 2017).

Abnormal birth weight is another health problem associated with maternal obesity during pregnancy. As compared with gravidas, who have BMI within the normal range, obese women are about two times more likely to have macrosomic children (Phillips et al., 2017). Giving birth to a fetus that weighs too much involves greater risks of obstetric complications, including bleeding, postpartum infections, various birthing difficulties, and traumas (Phillips et al., 2017).

Similarly, macrosomia affects children during the perinatal period due to the threat of birth traumas, including brachial plexus lesions, fractures, and shoulder dystocia (Beta et al., 2019). It is also critical that macrosomic newborns are among the risk groups for the development of hypertension, obesity, and related conditions later in life. In view of the abovementioned health issues associated with maternal weight status, weight monitoring during the prenatal period plays a significant role in disease prevention.

Investigating and Managing Prematurity: Care Required for Shai

According to the outcomes of the case, Shanvi gave birth to a baby boy. Shai, her newborn son, scored extremely low on the Apgar scale right after birth, but his condition gradually improved during the next ten minutes, partially due to active resuscitation efforts. In Shai’s case, nursing care decisions are to be made with reference to a variety of risk factors impacting the neonate. Among them is a low amniotic fluid index that is associated with adverse birth outcomes, the use of general anaesthesia during LSCS, and the mother’s use of fluoxetine during pregnancy. The most critical problems affecting Shai’s ability to survive and develop properly include the boy’s prematurity, extremely low birth weight (less than 1500 grams), and the signs of respiratory distress.

Just like any other preterm neonate with extremely low weight, Shai should be closely monitored to detect drastic changes and abnormalities in vital signs contributing to the threat of lethal outcomes. To prevent adverse events, healthcare specialists at NICU are to monitor the boy’s respiratory rate and heart rate on a regular basis (Warburton, Monga, Sampath, & Kumar, 2019). Monitoring and visual examination will allow checking for abnormally fast breathing, elevated heart rates, grunting during expiration, and skin discolouration – the most common symptoms of respiratory distress (Warburton et al., 2019).

If the neonate demonstrates the abovementioned signs, it will be necessary to use invasive or non-invasive respiratory support (CPAP) to stabilise breathing (Sweet et al., 2017; Warburton et al., 2019). If the respiratory distress syndrome actually develops in the boy, it will also be possible to use surfactants of bovine and porcine origin to reduce respiratory health risks (Sweet et al., 2017). The selection of management strategies will depend on the severity of health condition and breathing abnormalities.

Apart from heart rate and respiration, it is critical to monitor body temperature when caring for a premature baby. Both full-term and premature babies face increased risks of cold stress and are sensitive to temperature changes (Delanaud, Chahin Yassin, Durand, Tourneux, & Libert, 2019). To prevent health complications in Shai, caregivers are to exclude the presence of excessive clothing, inappropriate environmental conditions, and inflammatory processes causing temperature changes (Delanaud et al., 2019). Hypo- and hyperthermia can be extremely dangerous to preterm babies, and it is critical to monitor Shai’s body temperature when conducting any interventions.

Blood glucose levels should also be monitored and controlled in Shai’s medical situation. Earlier, his mother has been diagnosed with gestational diabetes, and babies of such women are at risk of having abnormal blood sugar levels. Blood glucose monitoring is needed to reduce the risks of hypoglycemia and resulting brain damages (Uettwiller et al., 2015). In particular, in the first days of Shai’s life, blood sugar levels are to be measured before and after feeding to check whether they are stable.

Besides health monitoring, specialists providing care for Shai are required to make decisions concerning feeding. Shai’s weight is extremely low, and proper nutrition should be provided to avoid further weight loss. Due to the boy’s health condition, he is to be kept at NICU, and Shanvi will not be able to breastfeed him. If Shanvi can express milk, she is to be encouraged to do so regularly. Shanvi is to give her consent to bottle-feeding with the help of infant formula in case there is no milk, or she faces other issues. Today, there are milk-based formulas created for premature and extremely underweight infants with attention to their unique nutritional needs. Such products can be used in Shai’s case to encourage weight gain.

Another measure that has to be taken when caring for Shai is to exclude the presence of neonatal withdrawal. This condition occurs in neonates if they develop substance dependence when they or their pregnant mothers are given drugs. Screening for neonatal abstinence syndrome (NAS) is critical in the case since Shanvi used fluoxetine during pregnancy to treat anxiety and sadness resulting from her father’s death. The use of fluoxetine and other SSRIs in the third trimester of pregnancy is associated with the signs of NAS in newborns (Convertino et al., 2016).

In utero exposure to this class of drugs, especially fluoxetine leads to NAS in 20-75% of cases (Convertino et al., 2016). Healthcare specialists are to assess Shai’s condition using NAS score every three or four hours. Attention needs to be paid to abnormal irritability, non-stop crying, visual signs of jaundice, problems with feeding, difficulty sleeping, seizures, and respiratory issues (Convertino et al., 2016). Vital signs data should also be used to make conclusions concerning the presence of NAS.

Postnatal Care and Management for Shanvi

Just like her newborn son, Shanvi deals with multiple health issues and requires monitoring and care to avoid complications and recover after preterm delivery. Earlier, the patient’s tests indicated renal abnormalities, and the healthcare team is to monitor Shanvi’s urine output and check for abnormalities in urination (Veena, Perivela, & Raghavan, 2017). Shanvi also had pre-eclampsia – in some cases, this condition recurs after delivery, so it is critical to control her blood pressure and use antihypertensive drugs as needed.

Shanvi has had a Cesarean preterm delivery, and although the procedure is relatively safe today, it is helpful to check for complications on a regular basis. In particular, the team is to pay attention to post-delivery blood loss to exclude abnormal bleeding (Moro et al., 2015). Normal discharge or lochia is red in colour, lasts for up to six weeks, and gradually becomes lighter with the lapse of time (Garg, 2018). Poor wound healing is among the most common complications after Cesarean section, and examining Shanvi’s uterine scar is critical in this regard. Other complications to be kept in mind include suture inflammation and wound infections (Moro et al., 2015).

To notice the key warning signs on time, the place of incision is to be examined with attention to redness and other skin colour abnormalities, severe pain, abnormal or intense wound discharge, and discomfort or pain in the legs or the abdominal area (Moro et al., 2015). Given that infections manifest themselves in fever-like symptoms, regular general health examinations are also necessary. It includes looking for severe dehydration, muscle pain, decreased appetite, headache, and high body temperature.

To facilitate Shanvi’s postnatal recovery, the healthcare team needs to take measures to avoid health complications linked with immobility. Deep vein thrombosis belongs to the number of such outcomes. This condition is characterised by the presence of blood clots in non-superficial veins, leg pain, localised swelling, and difficulty walking (Chen & Liu, 2019). As an obese woman who has given birth recently, Shanvi faces increased risks of developing this condition, especially if she gets used to extremely long bed rest and staying immobile (Chen & Lui, 2019). With that in mind, early mobilisation is recommended to increase the level of physical activity.

Shanvi’s current weight status is associated with additional health risks, and she has to receive care and patient education to start losing weight. When her health is stabilised, the patient is to be referred to a dietician to receive professional recommendations for weight loss. In postpartum women, the combination of a healthy diet, exercising, and self-monitoring is the most effective approach to weight normalisation (Lim et al., 2015). Shanvi’s dietary habits, pre-pregnancy level of physical activity, and potential causes of weight gain should be studied thoroughly to offer proper lifestyle interventions. Importantly, the selected dietary regime should have no impact on the quality of breast milk and help to maintain a healthy pace of weight loss.

In many cases, gestational diabetes resolves some time after delivery. However, it increases women’s risks of developing type 2 diabetes later in life (Billionnet et al., 2017). Due to the woman’s family history of diabetes and the frequency of iron deficiency anaemia in postpartum patients, Shanvi’s blood glucose and haemoglobin levels are to be monitored by the healthcare team on a regular basis. Moreover, to avoid unexpected health issues after hospital discharge, Shanvi should receive patient education on type 2 diabetes and its signs. In particular, the patient should be able to distinguish between hyperglycemia and hypoglycemia and understand the way that they affect general health. This knowledge will definitely help her to make good decisions in case of unusual symptoms.

Finally, from a long-term perspective, Shanvi can encounter problems related to her mental health, such as postnatal depression. Factors contributing to it include the patient’s relationships with her husband, her experience of loss, stress during and after pregnancy, and the history of psychological problems. With that in mind, it can be helpful to provide Shanvi with basic knowledge on the symptoms of postnatal depressive disorder and screen her for this condition every one or two months after hospital discharge.

Conclusion

To sum it up, to meet Shanvi’s and Shai’s complex health needs, the healthcare team is to monitor their condition, check for multiple complications, and provide specific education. For Shai, the required interventions are vital signs monitoring, regular bottle-feeding, checking blood sugar levels, and screening for NAS. Shanvi’s needs include blood glucose level monitoring, proper wound care and examinations, preventive measures against immobility complications, blood pressure control, and dietary interventions. Finally, to provide holistic care and benefit both the child and the mother, it is important to help Shanvi to cope with stress and monitor her mental health condition.

References

Beta, J., Khan, N., Khalil, A., Fiolna, M., Ramadan, G., & Akolekar, R. (2019). Maternal and neonatal complications of fetal macrosomia: A systematic review and meta-analysis. Ultrasound in Obstetrics & Gynecology, 54, 308-318.

Billionnet, C., Mitanchez, D., Weill, A., Nizard, J., Alla, F., Hartemann, A., & Jacqueminet, S. (2017). Gestational diabetes and adverse perinatal outcomes from 716,152 births in France in 2012. Diabetologia, 60(4), 636-644.

Chen, P. W., & Liu, P. Y. (2019). Postpartum deep vein thrombosis resolved by catheter-directed thrombolysis: A case report. Medicine, 98(24), e16052.

Convertino, I., Sansone, A. C., Marino, A., Galiulo, M. T., Mantarro, S., Antonioli, L.,… Tuccori, M. (2016). Neonatal adaptation issues after maternal exposure to prescription drugs: Withdrawal syndromes and residual pharmacological effects. Drug Safety, 39(10), 903-924.

Delanaud, S., Chahin Yassin, F., Durand, E., Tourneux, P., & Libert, J. P. (2019). Can mathematical models of body heat exchanges accurately predict thermal stress in premature neonates? Applied Sciences, 9(8), 1-11.

Garg, R. (2018). Puerperal sepsis with uterine scar dehiscence after Cesarean section: A rare complication. Journal of South Asian Federation of Obstetrics and Gynaecology, 10(2), 435-437.

Hope, O., Ifeanyi, O. E., & Braxton, A. Q. (2019). Investigation of some haematological parameters in pregnant women with gestational diabetes at Federal Medical Center, Owerri, Imo State, Nigeria. Annals of Clinical and Laboratory Research, 7(2), 1-6.

Lim, S., O’Reilly, S., Behrens, H., Skinner, T., Ellis, I., & Dunbar, J. A. (2015). Effective strategies for weight loss in post-partum women: A systematic review and meta-analysis. Obesity Reviews, 16(11), 972-987.

Moro, F., Mavrelos, D., Pateman, K., Holland, T., Hoo, W. L., & Jurkovic, D. (2015). Prevalence of pelvic adhesions on ultrasound examination in women with a history of Cesarean section. Ultrasound in Obstetrics & Gynecology, 45(2), 223-228.

Olusanya, B. O., Teeple, S., & Kassebaum, N. J. (2018). The contribution of neonatal jaundice to global child mortality: Findings from the GBD 2016 study. Pediatrics, 141(2), e20171471.

Phillips, J. K., Skelly, J. M., King, S. E., Bernstein, I. M., & Higgins, S. T. (2017). Associations of maternal obesity and smoking status with perinatal outcomes. The Journal of Maternal-Fetal & Neonatal Medicine, 31(12), 1620-1626.

Sweet, D. G., Carnielli, V., Greisen, G., Hallman, M., Ozek, E., Plavka, R.,… Visser, G. H. (2017). European consensus guidelines on the management of respiratory distress syndrome-2016 update. Neonatology, 111(2), 107-125.

Uettwiller, F., Chemin, A., Bonnemaison, E., Favrais, G., Saliba, E., & Labarthe, F. (2015). Real-time continuous glucose monitoring reduces the duration of hypoglycemia episodes: A randomized trial in very low birth weight neonates. PLoS One, 10(1), e0116255.

Veena, P., Perivela, L., & Raghavan, S. S. (2017). Furosemide in postpartum management of severe preeclampsia: A randomized controlled trial. Hypertension in Pregnancy, 36(1), 84-89.

Warburton, A., Monga, R., Sampath, V., & Kumar, N. (2019). Continuous pulse oximetry and respiratory rate trends predict short-term respiratory and growth outcomes in premature infants. Pediatric Research, 1-8. Web.

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