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CASE STUDIES

Proceedings of the 2012 AWHONN Convention

Breast Cancer Diagnosis While Breastfeeding: When Two


Worlds Collide
Womens
Health

Sue Hermann, RN, MN,


IBCLC, Sunnybrook Health
Sciences Centre, Toronto, ON
Beth Nolson, RN, IBCLC,
Sunnybrook Health Sciences
Centre, Toronto, ON
Keywords
pregnancy associated breast
cancer
breastfeeding
breast cancer
lactation

Background
he diagnosis of breast cancer is devastating and particularly stressful for the lactating
mother and her breastfeeding infant. The mother
must make treatment decisions that often include
having to abruptly stop breastfeeding. Management of breast cancer during lactation requires a
multidisciplinary approach with the nurse and/or
lactation consultant serving as important team
members. Lactating women receiving a diagnosis of breast cancer require immediate referral to
breastfeeding experts who are able to provide
them with support and accurate information on
weaning strategies. This presentation will utilize
a case study of a mothers experience of breast
cancer during lactation. The nurse and/or lactation
consultants role in identifying and referring suspicious breast lumps/infections will be outlined, and
ways to advocate for and support a woman with a
diagnosis of breast cancer during lactation will be
identified.

Paper Presentation
Case
Immediately after receiving a diagnosis of breast
cancer at a breast center, a 39-year-old mother
breastfeeding her 9-month-old infant presented
in the Breastfeeding Clinic, looking for weaning
support. Her infant was still breastfeeding seven
times per day, had started solids, and refused to
take a bottle or sippy cup. The lactation consultant worked with this mother to develop an individualized weaning plan. The mother was able to

gradually wean over a 2-week period without developing mastitis, a complication that could delay
her cancer treatment. In addition, because weaning is often traumatic for the mother/infant dyad,
the lactation consultant provided strategies to support the infant during the difficult transition from the
breast.
The advanced practice nurse, nurse practitioner
and lactation consultants reviewed the current literature on breast cancer diagnosed during lactation at a journal club and developed a pathway for
referring women who present in the breastfeeding
clinic with suspicious breast lumps and/or breast
infections.
Conclusion
r Only 3% of women develop breast cancer
while they are breastfeeding.
r Because of the aggressive nature of breast
cancer in this age group and the breast
changes that occur during pregnancy and
lactation that make detection more challenging, prompt referral of nonresolving suspicious breast lumps and/or breast infections
is imperative.
r Nurses/lactation consultants caring for
women in the postpartum period require
an awareness of diagnostic tests to rule out
or diagnose breast cancer, implications to
breastfeeding, and weaning strategies for
lactating women with a breast cancer diagnosis.

Supporting the Survivor: A Case Study


Cheryl Postlewaite, MSN, RN, Background
CCRN, WCNOCN, Mission
urvivors of childhood sexual abuse are at
Hospital System, Asheville, NC

Keywords
womens health
holistic health
wound care
sexual abuse

Womens Health
Poster Presentation

risk for a wide variety of sequelae, including


post-traumatic stress disorder, relationship disorders, pain disorders, and self-destructive behaviors. Studies report that between 7 and 34% of
women in the general population have survived
childhood sexual abuse. There is a large body of
evidence to support interventions for these survivors during their birth experiences. The purpose
of this poster is to demonstrate that those interventions can be successfully extrapolated into the
care of childhood sexual abuse survivors in other
health settings.
Fourniers gangrene, a polymicrobial necrotizing
soft tissue infection involving the genitalia requires

multiple surgeries, antibiotic therapy, and painful


wound care. This disorder challenges the patient
with changes in body image as well as the stress
associated with critical illness. When a childhood
sexual abuse survivor must face the necessary
treatment, there is an added layer of complexity;
helping her to feel safe and cope with care may
trigger severe psychological stress.
Case
This case involved a 60-year-old female survivor
with an established diagnosis of post-traumatic
stress disorder. Initially, it was medically necessary to provide wound care under general anesthesia. During the first dressing change outside of
the operating room, it was apparent to all that the

JOGNN
http://jognn.awhonn.org


C 2012 AWHONN, the Association of Womens Health, Obstetric and Neonatal Nurses

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CASE STUDIES
Proceedings of the 2012 AWHONN Convention

woman faced many challenges during this healing


process. Her initial response was to refuse further
care. She asked to be discharged with hospice,
rather than experience the trauma of further dressing changes. The wound care nurse was familiar
with the new survivor program in the community
and decided to offer this program to this woman
in the hope of making care acceptable.
Conclusion
The wound care nurse met with the woman
and elicited feedback about the specific fears,
triggers, and symptoms experienced during the

wound care procedure. They discussed potential


coping strategies, and the patient agreed to move
forward with care if she could be helped to feel
safe and in control of her body during treatment.
The multidisciplinary team met with the patient and
agreed upon a plan of care.
In longitudinal follow-up, the woman reported that
for the first time in 20 years she began to date
and later married with satisfactory sexual function.
The case study demonstrates that the nursing interventions used to help childhood sexual abuse
survivors cope during the birth experience may be
used in the treatment of other illnesses.

Gynecologic Oncology Patients: It Takes a Village


Background
ynecologic cancers affect more than 80,000
new women each year. Uterine cancer is
the fourth most common cancer in women, preceded only by lung, breast, and colon cancer.
In order to comprehensively and holistically care
for these women and their families, the primary
healthcare team must utilize a multidisciplinary
team approach.

Case
A 71-year-old woman has a history of uterine carcinoma for 10 years and breast cancer for 1 year.
She lost two children to cancer: a daughter to
breast cancer and a son to testicular cancer. She
lived with her husband and was admitted to the
hospital with the diagnosis of abdominal pain, nausea, and vomiting. Upon further evaluation she
was diagnosed with advanced metastatic uterine
carcinoma extending into both the bowel and the
liver. During her hospital stay she had multiple procedures, including an exploratory laporatomy and
tumor debulking with the creation of a colostomy.
She subsequently developed an entercutaneous
fistula, a deep vein thrombosis with lower extremity cellulitis, and multiple additional issues resulting from a severely immuno-compromised state.
The woman and her husband were determined to
beat this cancer, and she continued to receive

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chemotherapy during the first two and half months Elizabeth Ann Freund, RN-BC,
BSN, Inova Fairfax Hospital,
of her hospitalization.
Falls Church, VA

In order to meet the multidimensional needs of


this woman and her family, frequent collaborative
healthcare team meetings were held to coordinate
her care. A nutritionist was consulted prior to her
surgery due to her weakness, nausea, and vomiting. The nutritional support she received extended
throughout her hospitalization. An extensive medical team of experts in addition to her gynecologic
oncologists was consulted on her care including,
pulmonary, infectious disease, nephrology, gastroenterology, interventional radiology, and urology. The nursing team was instrumental in facilitating resources from the hospital including the
gynecology oncology nurse navigator, wound ostomy specialist, social worker, case management,
and animal assisted therapy. The Life with Cancer
team offered emotional and educational support
to both the husband and family. The womans goal
was to return home with her husband. She was discharged from the hospital to her home after 103
days with support from specialized home health
and palliative care services.

Janet Hooper, RNC, BSN, MA,


LCCE, Inova Fairfax Hospital
Womens Services, Falls
Church, VA
Patricia Schmehl, RN, MSN,
Inova Fairfax Hospital, Falls
Church, VA
Keywords
gynecologic oncology
womens cancer
multidisciplinary teams
palliative care

Womens Health
Poster Presentation

Conclusion
Nurses are the catalysts for facilitating multidisciplinary teams involving resources from the entire
healthcare arena. These teams assist in meeting
the patients needs and improving outcomes.

JOGNN, 41, S163-S188; 2012. DOI: 10.1111/j.1552-6909.2012.01363.x

http://jognn.awhonn.org

Kucharczyk, E. A. and Schick, L. O.

CASE STUDIES
Proceedings of the 2012 AWHONN Convention

Heart of the Matter: Myocardial Infarction in the Pregnant


Patient
Background
yocardial infarction during pregnancy is rare
with an estimated incidence rate of approximately 1 in 16,000 pregnancies and a case fatality rate of 11%. Though uncommon, pregnant
women are at increased risk of myocardial infarction due to normal physiological adaptations of
pregnancy, including increased circulating blood
Elizabeth A. Kucharczyk, BSN,
volume and other hemodynamic changes. AddiRNC-OB, Virginia Hospital
tional risk factors include hypertension, diabetes,
Center, Arlington, VA
preeclampsia, advanced maternal age, obesity,
Laura Olivia Schick, BSN, RN, multiparity, and smoking. Management of myocarVirginia Hospital Center,
dial infarction during pregnancy is complicated by
Arlington, VA
the potential effects of intervention on the develKeywords
oping fetus.

Childbearing

pregnancy
myocardial infarction
maternal morbidity
high risk pregnancy
coronary artery disease

Paper Presentation

Case
A 41-year-old multigravida patient presented to labor and delivery at 35 weeks gestation complaining of chest pain radiating down her left arm. A
stat electrocardiogram and cardiac enzymes tests
were obtained, and the patient had a computed
tomography scan (CT scan) to rule out dissecting aortic aneurysm. The initial electrocardiogram
showed normal sinus rhythm, but elevated troponin levels were indicative of an acute myocardial infarction. A cardiac catheterization determined the extent of the infarction, and the patient
was diagnosed with single-vessel coronary artery
disease of the left anterior descending coronary
artery. The patient was treated medically with heparin and scheduled for a repeat cesarean 2 weeks

after the initial attack. However, approximately 5


days after the episode, she experienced another
ischemic event increasing the urgency for delivery. A multidisciplinary team, including the patients obstetrician, house obstetrician, cardiologist, neonatologist, interventional radiologist, representative from blood bank, clinical nurse specialist, and labor and delivery charge nurse met
and planned for the birth. Nine days after the initial insult, the patient delivered a viable female infant via repeat cesarean under general anesthesia. After the surgery, the patient was transferred
to the intensive care unit for recovery. Over the
next several days, the patients hemoglobin and
hematocrit dropped requiring several blood transfusions, and a CT scan revealed two large rectal sheath hematomas. Heparin therapy was temporarily suspended until bleeding stabilized, and
the patient experienced no other complications.
She was discharged home on post-op on day 6.

Conclusion
As the prevalence of obesity and advanced maternal age increase, the incidence of myocardial
infarction during pregnancy is expected to rise.
Recognition of signs and symptoms of myocardial infarction in pregnant patients is essential to
early detection and intervention. Nurses serve a
crucial role in facilitating a multidisciplinary team
approach to promote effective, evidence-based
care of critically ill mothers and their infants.

One Contraction Too Many: Why Does It Really Matter?


Kristin Scheffer, RNC-OB,
C-EFM, Baylor University
Medical Center, Dallas, TX
Keywords
tachysystole
electronic fetal monitoring
(EFM)
fetal oxygenation
culture change
practice change

Childbearing
Paper Presentation

Background
ollowing the 2008 National Institute of Child
Health and Human Development update, our
healthcare system identified the need to educate all members of the perinatal team regarding
changes in electronic fetal monitoring definitions
and to make changes to our current practice for
early recognition and treatment of tachysystole.
Multiple modalities of education were employed,
especially surrounding the effects of tachysystole on the maternal-fetal dyad. Unfortunately,
these efforts did not significantly affect actual
practice.

Using a monthly strip review presenting the unexpected outcome of one patient, the multidisci-

JOGNN 2012; Vol. 41, Supplement 1

plinary teams throughout the Baylor Health Care


System gained a heightened awareness and understanding of the seriousness of tachysystole.
This strip review generated discussion regarding
the identification and appreciation of tachysystole and its effect on fetal oxygenation and fetal reserve. It was evident this case would affect the future practice of the perinatal healthcare
team.
Case
This case involves a gravida 1 para 0 at 39.6
weeks gestation with an uncomplicated pregnancy and a history of chronic hypertension.
The patient presented to labor and delivery for

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CASE STUDIES
Proceedings of the 2012 AWHONN Convention

cervical ripening and oxytocin induction. Her


admission tracing was Category I. During her induction, she developed persistent tachysystole.
Following fetal reserve depletion, the tracing deteriorated from Category I to Category III. Intrauterine resuscitation interventions resulted in a Category II tracing. Oxytocin was restarted. Consequently, the tracing deteriorated ending in a
terminal bradycardia. A stat cesarean was performed, and full neonatal resuscitation ensued.
APGAR scores were 0/1/2 at 1, 5, and 10 minutes, respectively. Umbilical cord gas and pH were
7.14 and 7.09, respectively. Initial neonatal arterial blood gas was pH 6.83, pCO2 19, bicarb
3.8, and initial blood sugars were in the 20s. The
infant was stabilized, transferred to the neonatal intensive care unit, and whole body cooling
was initiated. On day 13 of life, medical support

was withdrawn due to severe hypoxic ischemic


encephalopathy and renal failure after birth
depression.
Conclusion
Traditional methods to implement change in practice are not always effective. Presenting real cases
can truly affect the healthcare team. The realization, This can happen to us serves as a catalyst
for change. Until now, tachysystole was viewed
as benign in the presence of reassuring fetal
heart rate. By demonstrating how tachysystole affects fetal oxygenation and reserve and how a
physiologically normal fetus can suffer irreversible
consequences, this case has empowered the
healthcare team to be proactive in recognizing
tachysystole and intervening sooner, thus allowing for better outcomes.

A Case Study of Post Cesarean Pulmonary Embolism: Is


Prevention Possible?
Background
lthough relatively rare, when venous thromboembolism occurs in pregnancy or the postpartum period, it can be fatal with a background
occurrence rate of 0.6 to 1.8% and occurrence
along the spectrum of deep vein thrombosis to
pulmonary embolism. All members of the obstetric team must be aware of risk factors, common presentations, and treatment/intervention
strategies to ensure the best possible
outcomes.

Risk factors for venous thromboembolism in obstetrics should be the basis of a screening tool.
Although there is agreement that universal prophylaxis for venous thromboembolism does not have
a place in obstetrics, there is not agreement regarding the need for risk-based screening despite
a number of published tools. Available screening
tools and their usefulness in selected populations
will be reviewed. With the rising rates of obesity,
diabetes, and cesarean rates (reported in 2007
as 31.8%), the risk for venous thromboembolism
has never been higher. Participants will be given
tools to assist in implementing risk-screening
strategies for obstetric and high-risk obstetric
populations.
Ultimately when a pulmonary embolism is diagnosed, a complex, multidisciplinary response is
essential to mitigate tissue damage and improve
survivability. A flowchart of multidisciplinary re-

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sponses will be reviewed based on successful Susan Shannon Amos, RN,


interventions leading to improved outcomes in re- MSN, CNM, Vassar Brothers
Medical Center, Poughkeepsie,
ported PE.
NY

Case
Keywords
Mk was a 31-year-old gravida 2 para1 patient at pulmonary embolism
term presenting in spontaneous labor. Fetal dis- venous thromboembolism
tress was diagnosed during labor requiring an
emergency cesarean. The infant was born without
incident with Apgar scores of 8 at 1 minute and Childbearing
9 at 5 minutes. Approximately 15 hours postcesarean, the patient appeared to have a syncopal Paper Presentation
episode with resulting cardiac arrest. Intensive resuscitative measures were begun, including cardiopulmonary resuscitation and fluid resuscitation.
On trans-esophageal echo, a massive saddle embolus was seen in the right ventricle across the
tri-cuspid valve and into the pulmonary artery.
The patient initially survived surgical embolectomy
with complete cardiac bypass. However, she was
diagnosed with absent brain stem function and
clinical brain death approximately 72 hours postintervention after multisystem failure.
Conclusion
Although all obstetric patients do not require prophylaxis for venous thromboembolism, there is a
need for risk stratification for venous thromboembolism in high-risk populations. It is imperative that
obstetric providers review implementation of risk
based intervention criteria for venous thromboembolism.

JOGNN, 41, S163-S188; 2012. DOI: 10.1111/j.1552-6909.2012.01363.x

http://jognn.awhonn.org

Nueva, A., Boyle, C. J. and Mahoney, K.

CASE STUDIES
Proceedings of the 2012 AWHONN Convention

Abdominal Pregnancy: A Diagnostic and Management


Dilemma
Becky Nauta, MSN, RN,
CNML, Saint Marys Health
Care, Grand Rapids, MI
Keywords
OB rapid response team
ethics
abdominal pregnancy

Childbearing
Paper Presentation

Background
bdominal pregnancy accounts for up to 1.4%
of ectopic pregnancies. These pregnancies
can go undetected until an advanced gestational
age and often result in severe hemorrhage.

Case
A 29-year-old gravida 1, para 0 White woman was
admitted to the hospital due to a confirmed intraabdominal pregnancy. The patient was approximately 20 6/7 weeks based on ultrasound data.
The patient was seen by her family physician as
an outpatient and then referred to a perinatologist. The patient was found to have implantation
in the right lateral anterior uterus as well as the
right broad ligament and was admitted for additional imaging with potential surgery in 1 to 2
days. A computed tomography angiogram was
performed to assess the blood supply to the placenta for preoperative evaluation. The angiogram
showed the placenta to be implanted within the
right uterine wall and right broad ligament. An
ethics consult was requested by the perinatologist to explore all aspects of this case. The fetus
demonstrated adequate interval growth. Through
ethics case consultation, review of the ethical religious directives, other perinatologist expert opinions, and discussion with family and staff members, the decision was made to undergo uterine

embolization. A nurse from the labor and delivery perinatal loss team met with the patient and
family prior to the magnetic resonance imaging
and would remain with them throughout the remaining tests, surgery, and recovery period. Prior
to the magnetic resonance imaging, the patient
developed hypotension, tachycardia, and severe
intraabdominal and pelvic pain. The labor and delivery nurse initiated the call to the obstetric rapid
response team and directed the members to the
operating room suite. Upon arrival in the operating room, the patient had a severe bradycardic
episode and hypotension with progression to a
lack of pulse, consistent with hemorrhagic shock.
The patient did not require cardiopulmonary resuscitation as she responded to vasopressors.
The fetus was delivered within 5 minutes of arrival in the operating room and was stillborn. After
receiving six units of red blood cells, six units of
fresh frozen plasma, and six units of platelets, she
was moved to the intensive care unit. Estimated
blood loss was 3,500 cc.
Conclusion
Over the next 5 days, the patients condition was
closely monitored. Nursing care was provided by
intensive care unit and labor and delivery staff in
an effort to meet all aspects of the critically ill obstetric patient and her family.

Too Young and Too Pregnant to Die: H1N1 and Pregnancy


Awina Nueva, RNC, Robert
Wood Johnson University
Hospital, New Brunswick, NJ
Carla J. Boyle, BSN, RN-C,
Robert Wood Johnson
University Hospital, New
Brunswick, NJ
Kathleen Mahoney, APN,
Robert Wood Johnson
University Hospital,
Whitehouse Station, NJ
Keywords
H1N1
influenza
adolescent pregnancy

Background
1N1 is known to cause catastrophic complications in the pregnant population. In this
case we review the presentation and sequelae of
such a patient.

were developed for an intensive care unit cesarean if needed. The patient ultimately did require
an emergent delivery and died quickly thereafter.
The case was complicated by the patients age
and culture.

Case
A gravida 1 para 0 17 year old with adequate prenatal care who refused a flu shot presented to labor and delivery with flu like symptoms early in
the third trimester. The patient rapidly progressed
to acute respiratory distress syndrome and plans

Conclusion
Patient education is vital regarding the importance
of flu vaccine. Multidisciplinary efforts were required to try to save this patients life, care for her
extremely preterm infant, and support her grieving
family.

Childbearing
Poster Presentation

JOGNN 2012; Vol. 41, Supplement 1

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CASE STUDIES
Proceedings of the 2012 AWHONN Convention

Trauma for Two


Background
he purpose of this session is to offer practicing
bedside nurses a look at a collaborative approach to assessing and intervening for obstetric
patients with trauma and sequelae. A clear understanding of the physiologic changes in pregnancy and how those changes impact the plan
of care will promote patient safety and enhance
nursing care. Utilizing a case analysis method,
this session will focus on the indications for alternatives in the plan of care when the trauma
patient is pregnant, including blood volume and
composition changes, changes in cardiac output,
tidal volume changes in respiratory status, and
impact of the gravid uterus on anatomy and physiology of systems. Special consideration will be
given to pharmacologic agents and their use during pregnancy and lactation. Patient outcomes are
enhanced when nurses understand the implications of changes to anatomy and physiology in the
pregnant patient. The target audience for this session includes progressive and critical care bedside nurses, obstetric nurses, educators, and advanced practitioners. Participants should have a
basic understanding of hemodynamics, trauma,
and pregnancy.

Case
The complex trauma case presented involved an
automobile crash in which the victim suffered multiple fractures to her cervical spine and subsequently quadriplegia. The care she received during a 51-day acute care hospital stay involved
many disciplines and coordination of interdisciplinary care. Her care was complex and collaborative until the final transfer of her care to another
facility. Her case study will be used as teaching
points to outline best practice for all trauma patients. A discussion of medications used in her
care will be if interest to the staff and advanced
practice nurse. This case study is the result of severe, life-threatening injury to the woman. A second case will be briefly described in which a
mother sustained serious but not life-threatening
injuries, and the fetus sustained life-threatening
injuries.

Susan Spencer, MSN,


RNC-OB, IBCLC, C-EFM,
Trinity Mother Frances
Hospitals and Clinics,
Tyler, TX
Keywords
trauma
hemodynamics
injuries
interdisciplinary care

Childbearing
Poster Presentation

Conclusion
Care of the obstetric trauma patient is at once
simple and complex. If there is no damage to the
pelvis or fetus, with the proper care the pregnancy
remains intact and the fetus can be expected to
grow and thrive. Conversely, the care for the pregnant patient can become very complex, and the
type of injuries can adversely affect the fetus while
care to the mother remains relatively simple.

Eclampsia and the Ugliness That Follows


Background
osterior reversible encephalopathy syndrome
is an uncommon finding following eclamptic
seizures and subsequent fetal demise in a previously healthy primigravida.

Case
A primigravida at term with no complicating factors in her pregnancy suffered an eclamptic
seizure at home and was admitted to the closest healthcare facility in hypertensive crisis. She
suffered another seizure upon her arrival and was
subsequently diagnosed with an intrauterine fetal
demise. She initially received intravenous magnesium sulfate, intravenous hydralazine, and intravenous labetalol to treat her hypertensive crisis.
She was started on oxytocin to induce vaginal
birth and an epidural catheter was placed for labor analgesia. During this time, she underwent a
head computed tomography, which revealed extensive abnormalities in both the cerebral hemi-

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spheres consistent with posterior reversible encephalopathy syndrome. The patient spoke Spanish as her primary language and was lethargic for
most of the first 24 hours of hospitalization, arousing briefly only to answer simple questions. The
patient was transferred prior to active labor to the
intensive care unit where she was monitored for
possible neurologic deterioration. A labor and delivery nurse accompanied the patient, managed
her oxytocin infusion, and supported her through
a vaginal delivery of a stillborn fetus. The patient
had significant but lessening neurologic deficits
by time of discharge.
Conclusion
By analyzing and assessing patient data, observing, and planning, a safe outcome for this patient
was affected. Obstetric and critical care nurses
coordinated patient-specific interventions to direct
outcomes and worked together to re-evaluate patient stability.

JOGNN, 41, S163-S188; 2012. DOI: 10.1111/j.1552-6909.2012.01363.x

Yvonne A. Dobbenga-Rhodes,
MS, RNC-OB, CNS, CNS-BC,
Washington Hospital
Healthcare System, Fremont,
CA
Keywords
eclampsia
posterior reversible
encephalopathy syndrome
fetal demise

Childbearing
Poster Presentation

http://jognn.awhonn.org

CASE STUDIES

Gelato, J., Holleran, D. and Skinner, N.

Proceedings of the 2012 AWHONN Convention

Urinary Tract Infection at 9 Weeks, Vasculitis at 13 Weeks,


Neck Pain at 21 Weeks. Frequent Flyer Syndrome? A Case
Study of Non-Hodgkins Lymphoma Diagnosed at 27 Weeks
April Caruso, MSN, APN/CNS, Background
RNC, Central DuPage Hospital,
ymphoma is now the fourth most diagnosed
Winfield, IL
Keywords
non-Hodgkins lymphoma in
pregnancy
interdisciplinary teams
best outcomes

Childbearing
Poster Presentation

malignancy during pregnancy, occurring in


approximately 1:6,000 births. With the delay in
childbearing and the increase in primiparous maternal age it can be expected that cancer will be
diagnosed more frequently in pregnant women.
Since non-Hodgkins lymphomas occur in an older
patient population than Hodgkins lymphomas, this
may account for fewer reports of non-Hodgkins
lymphoma patients with coexisting pregnancies.
When a diagnosis is made, issues surrounding
decisions regarding the approach to treatment options are extremely complex and must include the
medical and obstetric health of both the mother
and fetus.

Case
A gravida 1, para 0, 25-year-old married patient
had multiple encounters with the healthcare system during her first and second trimester until being diagnosed with non-Hodgkins lymphoma at
27 to 28 weeks. An interdisciplinary team was
formed and invites went out to the perinatology,
oncology, obstetrics, spiritual services, palliative
care, and social services departments. The patients initial plan was to start the first round of
chemotherapy to help with her pain and reduce
the nodules in her neck. It was clear to the team

that a plan with ongoing communication must be


determined. Less than 2 weeks later the patient
was readmitted for intractable head pain. A lumbar puncture confirmed cancer cells in her cerebral spinal fluid. She would now need to be treated
with chemotherapy in her brain through placement
of an Ommaya reservoir, a device surgically implanted under the scalp used to carry medicine to
the brain and spinal cord. Her delivery was scheduled and would be complicated by her extremely
low platelet and white blood cell counts.
The most critical and challenging issues for the
team involved managing the patients pain, treating her cancer, and monitoring maternal wellbeing and fetal development. Her care was complicated by her physical location in the hospital,
family dynamics, and need for prenatal education
and rest. She gave birth to a female infant vaginally at 30 + 6 weeks.
Conclusion
The diagnosis of cancer during pregnancy is rare
but may increase in the future. Through an interdisciplinary team effort that includes the obstetric
nurse, we can accept the challenges that accompany the pregnant oncology patient and promote
evidenced-based best practice to provide continuity of physical, psychological, and spiritual care
for optimal outcomes.

Heartbreak to Happiness: Striving to Improve Outcomes


for the Patient in Diabetic Ketoacidosis
Jill Gelato, BSN, RNC,
Background
Christiana Care Health System,
iabetic ketoacidosis (DKA) is an acute, maSwedesboro, NJ

jor, life-threatening complication of diabetes

Dianne Holleran, BSN, RNC,


that warrants prompt recognition and a multidisChristiana Care Health System, ciplinary approach to provide intensive manageNewark, DE
ment and monitoring of both mother and fetus.
Nancy Skinner, MSN, RNC,
Christiana Care Health
Services, Newark, DE

DKA is estimated to occur in 1 to 2% of pregnancies complicated by preexisting diabetes, with 10


to 30% of women having a serum glucose less
than 250 mg/dl upon diagnosis, and it poses a
significant risk for the fetus, with perinatal mortality
rates reported between 9% and 35%. Factors that
increase the risk of DKA in pregnant patients include stress, trauma, infection, poor patient compliance, insulin pump failure, accidental omission
of insulin, and medications utilized in the obstetric

JOGNN 2012; Vol. 41, Supplement 1

setting. It is crucial that nurses are familiar with


the clinical signs of DKA so that prompt and appropriate treatment can be initiated to optimize
outcomes for both the pregnant woman and her
fetus. To better understand the signs and symptoms of DKA, an outline of the multisystem effects
of a patient in DKA will be provided.
Case
The presentation follows the case of a patient
who recently gave birth to a healthy 38-week
male infant. Her previous pregnancy and birth
resulted in an intrauterine fetal demise following an episode of DKA. We will present a timeline
that outlines the course of both pregnancies and
the patients progression from grief to acceptance.

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CASE STUDIES
Proceedings of the 2012 AWHONN Convention

Keywords

Conclusion
A problem solving method aimed to identify the
root cause of an event, known as a Root Cause
Analysis, was conducted utilizing a multidisciplinary team to review and discuss the case. Opportunities were presented to improve patient care

and patient outcomes of the diabetic patient ad- pregnancy


mitted with a diagnosis of uncontrolled blood sug- diabetic ketoacidosis
intrauterine fetal demise
ars in recognition of DKA. The team decided to
develop a Diabetic Ketoacidosis MD order set and
to provide online education and education in the
formal classroom setting for resident and nursing Childbearing
staff.

Poster Presentation

Cancer in Pregnancy: When Two Worlds Collide


Background
ancer occurs during pregnancy at a rate of
approximately 1 in 1,000 pregnancies. Due
to recent trends of postponed childbearing this
rate may actually be increasing as age is a notable risk factor for many types of cancer. A cancer diagnosis may be delayed because symptoms
of cancer may mimic normal changes of pregnancy. Cancer is perceived as an assault to the
well-being of the woman and her unborn child. Despite differing circumstances associated with this
diagnosis, there are many commonalities related
to the moral, psychosocial, and ethical issues of
treatment.

Mrs. J. was diagnosed at 30 weeks gestation


with a neuroendocrine neoplasm of the pancreas
with metastasis to the liver. Her symptoms were
masked by her pregnancy causing a delay in diagnosis. Her treatment consisted of a liver biopsy
to confirm the diagnosis, stent placement, amniocentesis for fetal lung maturity, and cesarean,
which was coordinated with surgical oncology for
visual inspection of her liver to determine progression of the cancer. Postoperatively she began chemotherapy and was able to successfully
breastfeed her infant during treatment. She continues outpatient chemotherapy treatment and is
doing well.

Cases
Mrs. S. was diagnosed with recurrent glioblastoma multiforme at 17 weeks gestation. Her treatment consisted of surgery to debulk the tumor, chemotherapy, physical therapy, cesarean at
30 weeks gestation, and palliative care after birth.
Despite a grim diagnosis she continued postpartum chemotherapy hoping for a cure. She died 3
months after the birth of her child.

Conclusion
Despite the traumatic experience of diagnosis and
treatment of cancer during pregnancy, a favorable outcome may be achieved with the birth of
a healthy newborn. There are many complexities
to be navigated during the treatment of cancer in
pregnancy. Making treatment decisions is a collaborative effort between the patient, oncologist,
surgeon, nurse, and obstetrician. Careful planning
optimizes safety for both the woman and her unborn child.

Janice Denny Gibbs, MSN,


RNC, Norton Hospital,
Simpsonville, KY
Glenda C. Babcock, RN, BS,
IBCLC, Kosair Childrens
Hospital, Louisville, KY
Keywords
pregnancy
cancer
chemotherapy

Childbearing
Poster Presentation

Placenta Percreta: Enhancing the Family Experience


Background
gravida 4, para 3 patient with known precreta and placenta previa came to Rockford
Memorial Hospital during her fourth pregnancy.
She was married, 39 years old, and a practicing Catholic. She had issues with spotting during
her pregnancy and had ultrasound examination to
confirm previa. She received confirmation of percreta at Rockford Memorial Hospital. The patient
took sertraline and prenatal vitamins daily, did not
drink or smoke, had mild asthma an used an albuterol inhaler occasionally. She denied any other
medicine or drugs ingestion and had three previous cesareans.

S170

Case
The patient was admitted prior to her cesarean/hysterectomy to the high-risk perinatal unit.
She then had the opportunity to talk with representatives from nursing, neonatology, perinatology, and anesthesiology, and we answered her
and her husbands questions. She was instructed
to make a living will, which she had done before
admission. She was nervous but also excited to
see her infant.
Conclusion
The cesarean/hysterectomy was performed in a
very deliberate order. Various lines were placed

JOGNN, 41, S163-S188; 2012. DOI: 10.1111/j.1552-6909.2012.01363.x

Linnette E. Carter, MS,


RN-BC, APN, Rockford Health
System/Rockford Memorial
Hospital, Rockford, IL
Mary J. Cascio, BSN,
RNC-OB, Rockford Health
System/Rockford Memorial
Hospital, Rockford, IL
Patricia L. Aronson, BSN,
RNC-OB, Rockford Health
System/Rockford Memorial
Hospital, Rockford, IL

http://jognn.awhonn.org

CASE STUDIES

Hickey, M. T.

Proceedings of the 2012 AWHONN Convention

Keywords
placenta percreta
joyous birth
family experience

and the procedure was done under spinal anesthesia. Her husband was at her side during the
cesarean section, and he and the patient were
able to see the infant after birth. The patient
then was put under general anesthesia for the

remainder of the surgery. She had bladder involvement, so the proper surgeons where there
for that part of the surgery. After recovery from
surgery, she was discharged and resumed her
life.

Childbearing
Poster Presentation

Caring for the HIV Positive Patient with Premature Rupture


of Membranes at 28 Weeks
Diana Rich, BSN, RNC-OB,
Baylor University Medical
Center, Dallas, TX
Kelli Bural, BSN, RNC-OB,
C-EFM, Baylor University
Medical Center, Dallas, TX
Keywords
HIV
preterm premature rupture of
membranes
antiretroviral therapy

Childbearing
Poster Presentation

Background
his presentation discusses the management
of a multiparous HIV positive patient who was
admitted to Baylor University Medical Centers labor and delivery unit with premature rupture of
membranes (PROM) at 28 weeks gestation. A multidisciplinary approach was taken to provide the
best care to the maternal-fetal dyad.

it was decided to continue her prenatal antiviral


drug regimen. Repeat CD4 count and viral load
lab work were performed confirming undetectable
viral load. The patient received a psychological
consult for her depression and anxiety and an occupational therapy consult for her demyelination
syndrome. She was counseled regarding contraceptive care and bottle feeding as the preferred
method to reduce transmission.

Case
This case involves a gravida 3, para 1 who presented to labor and delivery 28 5/7 weeks gestation with PROM. Her obstetric history included one
spontaneous abortion and one 24-week preterm
delivery of an infant who died at 8 days of life.
Her medical history was complicated by positive
HIV infection, bipolar depression, multifocal demyelination disorder, and advanced maternal age.
Her HIV status was diagnosed during her current
pregnancy, and she was placed on a combination
antiretroviral regimen. Her last viral load prenatally
was undetectable.

At 29 5/7 weeks, she began experiencing cramping, vaginal bleeding, and signs of chorioamnionitis. She was transferred to labor and delivery, where the decision was made to proceed
with a cesarean. Per guidelines of the Centers for
Disease Control and Prevention, intravenous AZT
was started and allowed to infuse for the recommended 3 hours prior to birth. The infant was born
with 8/9 Apgar scores, was bathed and transferred
to the NICU on room air. The infant was started on
antivirals, with a plan to continue for the first 6
weeks of life.

Upon presentation to labor and delivery, she


stated she had been leaking fluid for 11/2 hours.
No signs of labor or vaginal bleeding were noted
on admission. Rupture of membranes was confirmed. She was placed on latency antibiotics and
given corticosteroids for fetal lung maturation. Following consultation with representatives from infectious disease, the neonatal intensive care unit
(NICU), maternal fetal medicine, and neurology,

Conclusion
When PROM occurs prior to 37 weeks, decisions
about delivery should be based on gestational
age, duration of rupture, HIV RNA level, current
antiretroviral regimen, and evidence of acute infection. It is essential to provide ongoing training
and the most current recommendations for management of HIV infection for the labor and delivery
staff.

Asthma in Pregnancy
Mary T. Hickey, EdD,
WHNP-BC, New York
University, New York, NY

Background
sthma is a chronic airway disorder affecting
22 million Americans. The pathophysiology of
asthma is complex, involving inflammation, airway
constriction, and airway hyper-responsiveness.
Asthma is one of the most common medical
conditions affecting pregnant women, complicating approximately 8% of all pregnancies. Asthma
may improve or worsen with pregnancy; however, various reports have noted the increased risk
for preeclampsia, intrauterine growth restriction,

JOGNN 2012; Vol. 41, Supplement 1

preterm birth, and perinatal mortality in pregnancies complicated by asthma. Asthma is classified
by severity of symptoms as well as degree of lung
compromise; various ventilatory studies are used
for diagnosis and treatment planning. Treatment
plans for asthma are aimed primarily at improving oxygenation, preserving lung function, and
reducing symptoms and exacerbations. Pharmacologic management usually includes shortacting bronchodilators, long acting inhaled corticosteroids, occasional histamine blockers, or

S171

CASE STUDIES
Proceedings of the 2012 AWHONN Convention

leukotrine modifiers in a step-up approach. During pregnancy, goals of treatment and management of asthma focus on the promotion of fetal
oxygenation, prevention of hypoxia, and ongoing
assessment of fetal well-being.

ula as needed. Fetal monitoring was done intermittently; she had three biophysical profiles during her stay. Fifty hours after admission a fetal
demise was suspected during a routine assessment, which was later confirmed by sonogram.

Case
The patient was a 34-year old gravida 7 para
3033 who presented at 10 weeks gestation. Her
past medical history was significant for asthma
with meds. Her prior obstetric history was unremarkable; her last delivery was 2 years prior.
This pregnancy was uncomplicated until 34 weeks
gestation when she presented with a cough and
shortness of breath; she was treated with antibiotics. At 38 weeks gestation, the patient was hospitalized after complaints of shortness of breath
and a cough for an acute asthma exacerbation
with hypoxia. Her treatment plan included shortacting bronchodilator nebulizer treatments and intravenous corticosteroids and antibiotics. She was
provided with supplemental oxygen by nasal can-

Conclusion
This case highlights the unpredictable course of a
pregnancy complicated by asthma and the complexities of management. It is essential that nurses
working with pregnant patients perform comprehensive assessments and histories and recognize
the implications of identified actual and potential health problems. Nurses using electronic fetal
monitoring must be skilled in assessment and interpretation of data and possess the knowledge
to utilize additional surveillance measures to assess fetal well-being. Communication and collaboration between members of the interdisciplinary
health care team, in a timely effective manner, are
essential to promote the best possible outcomes.

Keywords
asthma
pregnancy
fetal well-being

Childbearing
Poster Presentation

Gestational Time Bomb, a Case Study of Abdominal


Pregnancy, a Rare Birth
Background
xtrauterine pregnancies are extremely rare,
occurring in only 1% of pregnancies, with
98% of those located intratubal. They result in a
perinatal mortality rate between 40% and 95% due
to massive hemorrhage. The most common management of this condition is removal of the fetus
with a hysterectomy. Nurses have a pivotal role as
advocates for patents.

Case
A 25-year-old female patient presented to a tertiary facility with a diagnosis of an abdominal pregnancy. The patient was admitted at 24 weeks,
gravida 2, para 1, and all prenatal labs were within
normal limits. The ectopic pregnancy was confirmed by magnetic resonance imaging and exploratory laparoscopic surgery. Although termination of the pregnancy was recommended, the
patient elected to continue the pregnancy. The
nurses supported her decision and gave her daily
encouragement. The patient remained hospitalized and on bed rest for 8 weeks before giving
birth.
The patients plan of care included collaboration
between multidisciplinary teams from many specialties and clinical experts within the hospital. Because the location of the placenta and how pregnancy was affecting other adjacent organs was
unknown, there was concern regarding the devel-

S172

opment of the fetus and when delivery should occur. Potential risks included the possibility that the
placenta might grow into the peritoneum, bowel,
bladder, or omentum, possible fetal growth restriction, rupture of membranes, or bleeding. As a result, all abdominal complaints were taken under
serious consideration.
Nurses used an evidence-based approach to
manage the patients physical and emotional concerns. Fear and stress can cause vasoconstriction
and reduce cardiac output. Holistic care was provided by utilizing complementary therapies to help
to reduce anxiety and discomfort,which included
chaplain services, arts/crafts, healing touch, and
pet, music, and hydro therapy. Surgery to deliver
the infant revealed the pregnancy in the cornual
horn. There has been no documentation of a pregnancy exceeding 12 weeks in this location. The
patient gave birth to a 32-week viable boy, weighing 1,400 grams, and we were able to preserve
her uterus for future pregnancies.

Letreyona Jenkins, RN, Banner


Good Samaritan Medical
Center, Phoenix, AZ
Christina Tussey, MSN, CNS,
RNC-OB, RNC-MNN, Banner
Good Samaritan Hospital,
Phoenix, AZ
Mary J. Wolf, BSN, RNC,
Banner Good Samaritan
Medical Center, Glendale, AZ
Keywords
abdominal pregnancy
intrapartum emergency
ectopic pregnancy

Childbearing
Poster Presentation

Conclusion
Collaboration is very important for high-morbidity
risk cases for optimal patient outcomes. Perinatal
nurses must be prepared for the potential intrapartum catastrophe with proactive and anticipatory nursing, critical assessment skills, and psychosocial care to ensure a positive pregnancy and
birth for the mother and fetus.

JOGNN, 41, S163-S188; 2012. DOI: 10.1111/j.1552-6909.2012.01363.x

http://jognn.awhonn.org

CASE STUDIES

Banner, S. and Benson, V. L.

Proceedings of the 2012 AWHONN Convention

Calling All Obstetric Nurses: Be On the Look Out for Liver


Rupture
Gina M. Scott, BSN, RNC-OB, Background
Christiana Care Health System,
iver rupture is a rare life threatening complicaHockessin, DE

tion of severe preeclampsia and hemolysis el-

Theresa Rollo, BSN, RNC-OB, evated liver enzymes and low platelets syndrome.
Christiana Care Health System, This syndrome occurs in one of 225,000 pregNewark, DE
nancies, and our institution has had three cases
Keywords
liver rupture
collaboration
interventions

Childbearing
Poster Presentation

since July 2009. Liver rupture presents a unique


challenge to even the well-seasoned, experienced
nurse. The purpose of this presentation is to help
nurses recognize the potential for liver rupture and
empower them with nursing interventions to care
for patients experiencing this emergency.

Case
A 29-year-old 27-week gestation patient arrived in
obstetric triage from her physicians office with elevated blood pressure, trouble focusing, and +2
proteinuria. After evaluation she was admitted to
the antenatal unit for further monitoring. On day
3 she complained of severe epigastric pain and
was transferred to the high-risk obstetric department. General surgery, perinatology, neonatology,
and anesthesia representatives were immediately
consulted. After intervention to treat her hypertension and review of the diagnostic and laboratory
results, a decision was made to proceed with a
cesarean delivery.

Postoperatively liver enzymes became grossly


elevated and she developed disseminated intravascular coagulation necessitating transfusion
of blood products. Despite the transfusion, her
condition continued to deteriorate and a collaborative decision was made to return the patient
to the operating room for exploratory surgery. A
significant intra-abdominal hemorrhage with subscapular hepatic hematoma rupture was found.
The patients recovery was complicated by the
need for ventilator assistance, dialysis, interventional radiology, and multiple trips back to the
operating room. The patient was discharged
after a lengthy 22-day hospitalization with no
long-term sequelae. If not for the multitude of
dedicated healthcare team members and their individual contributions, this patient may not have
been successfully diagnosed and treated.
Conclusion
Although liver rupture is a rare occurrence, nurses
need to diligently monitor patients with HELLP syndrome for signs and symptoms of this catastrophic
event. Labor units can be better prepared to intervene by having specialized equipment immediately available. Clear communication among the
healthcare team is essential to ensure a successful outcome.

Respiratory Failure in a Pregnant Patient with Pyelonephritis


Sheryl Banner, BSN, RNC,
Background
Christiana Care Health System,
n this presentation we describe the manageHockessin, DE

ment of a patient at 28 weeks gestation, admit-

ted for pyelonephritis, who ended up in respiratory


Vikki L. Benson, BSN, RNC,
Christiana Care Health System, failure.
Townsend, DE
Keywords
pyelonephritis
respiratory failure
ARDS

Childbearing
Poster Presentation

Case
The patient complained of fever, headache, and
back pain. Vital signs were 37.3 C, 138 heart rate,
20 respiratory rate, 98/50 BP. She had gram negative rods on the gram stain from her urine sample,
so she was admitted for pyelonephritis to our obstetric high-risk unit for continuous fetal monitoring
and antibiotic and analgesic therapy.
Her temperature rose to 39.5 C and she was
tachypneic. Her hemoglobin dropped to 6.8, so
she was transfused. A chest x-ray was used to
diagnose right lower lobe pneumonia. Her oxygen saturation rates (O2 sats) were 70 to 80%,
and adult respiratory distress syndrome was suspected. The patient was transferred to the inten-

JOGNN 2012; Vol. 41, Supplement 1

sive care unit due to the concern that she may


have to be intubated for ventilatory support. Escherichia coli grew in her urine culture. She continued with tachypnea, labored breathing, and developed a productive cough. She was considered
critically ill and in respiratory failure but was able
to be sustained on oxygen therapy without intubation. She eventually was weaned to room air, with
O2 sats > 95%.
The patient was discharged after a week, still
pregnant, with orders for monthly urine cultures
and suppressive therapy. Her only readmission
was when she was in labor at 40 weeks gestation.
She had normal vital signs at that point and had
no oxygen requirements. She delivered a healthy
term infant with Apgar scores of 8 and 9.

Conclusion
A paucity of recent literature has addressed
the relationship between pyelonephritis and

S173

CASE STUDIES
Proceedings of the 2012 AWHONN Convention

respiratory distress in pregnancy. Nonetheless, we


seem to be encountering this problem more frequently. The association of pyelonephritis and respiratory distress in pregnancy was first described
in 1984. Pyelonephritis alone is estimated to occur in 1 to 2% of all pregnancies. Some studies
suggest that one out of every 50 women admitted
for pyelonephritis will develop some respiratory
distress. Unfortunately, the etiology for the mechanism of the syndrome remains unknown.

Respiratory distress in pregnancy is associated


with a high rate of perinatal morbidity and mortality. It is fortunate that this patient had access
to an institution where she could have maternal fetal medicine and pulmonology consults. Her
management prevented artificial ventilation, which
would have increased her statistical risk. Providing care for this patient and others like her has
increased our awareness of the possible consequences of urinary tract infections in pregnancy.

Fetal Supraventricular Tachycardia with Hydrops and 1:1


Atrioventricular Block in a Pregnant Patient with a Sinus
Arrhythmia
Background
e describe the management of a patient
at 27-weeks gestation, admitted for fetal
supraventricular tachycardia (SVT) and ascites.

Case
Fetal tachycardia was evident at 17-weeks gestation, however the patient did not follow-up with
medical recommendations. Fetal SVT was subsequently confirmed by ultrasound, with a fetal heart
rate of 235 to 240 along with ascites. She was admitted to our obstetric high-risk unit under the care
of our maternal fetal medicine physicians, with a
plan for continuous fetal monitoring and digoxin
therapy. The patient had an arrhythmia herself
upon admission, with no prior history. Her electrocardiogram reflected a sinus arrhythmia. The
fetal heart rate was in the 240s until antiarrhythmic
administration to the mother. The patient was informed that there was a 20% risk of therapy failure
and a 25 to 30% risk of fetal mortality.
Daily electrocardiograms and consults with cardiology, pediatric cardiology, and neonatology were
ordered. A 1:1 atrioventricular (A/V) block was
confirmed by fetal echocardiogram. Propranolol
was added to the digoxin plan. In spite of this,
the fetus only converted to sinus rhythm for 4 to
6 beats, 1 to 2 times per minute. The fetus also
developed pericardial effusions. Flecainide was
added, but consent was also obtained for the possible administration of adenosine via a cordocen-

S174

tesis procedure. The addition of flecainide converted the fetus to normal sinus rhythm, and the
ascites resolved. The patient was discharged with
a prescription for flecainide and biweekly ultrasounds.
The only readmission for the patient was at 39
weeks, when she was scheduled for an induction
of labor. The patient was still taking flecainide and
continued this through labor. The fetal heart rate
was 110 to 120 on admission, and the patients
vital signs were normal. The patient had a repeat
neonatology consult prior to delivery, so she was
informed that the newborn would be going to the
neonatal intensive care unit following birth for cardiac monitoring. She had an uneventful birth, and
the newborn had 9/9 Apgar scores. The newborn
had a normal heart rate, but the electrocardiogram
result was questionable for A/V block. The newborn had persistent normal sinus rhythm subsequently and was discharged on no medications
but did have follow-up appointments with a pediatric cardiologist.

Sheryl Banner, BSN, RNC,


Christiana Care Health System,
Hockessin, DE
Lori H. Smith, BSN, RNC,
Christiana Care Health System,
Pennsville, NJ
Keywords
fetal supraventricular
tachycardia
ascites
hydrops

Childbearing
Poster Presentation

Conclusion
This was a successful multidisciplinary effort that
resulted in the delay of birth until term for an infant who had refractory SVT, hydrops, heart block,
and pericardial effusions. The morbidity and mortality risks are high with such a combination, so
the patient benefited from a team with a wealth of
experience.

JOGNN, 41, S163-S188; 2012. DOI: 10.1111/j.1552-6909.2012.01363.x

http://jognn.awhonn.org

CASE STUDIES

Wyatt, S.

Proceedings of the 2012 AWHONN Convention

Tin Man Syndrome: Avoiding the Shock and Keeping


Pace with a Maternal Implantable Cardioverter Defibrillator
Pacemaker and Neonatal Tetrology
Kimberly M. Beckwith, RN,
BSN, Edward Hospital,
Naperville, IL
Keywords
Tin Man
ICD/pacemaker
tetrology of fallot
abruption
pregnancy and cardiac
anomalies

Childbearing
Poster Presentation

Background
ardiac disease occurs in approximately 1%
of all pregnancies. Tin Man syndrome,
though rare, is a disorder encompassing physical
and/or electrophysiological cardiac mutations that
may present at any time in life. Historically, women
with cardiac anomalies were discouraged from
pregnancy. While medical advancements have increased the possibility of pregnancy in this population, they may also be minimizing the perception
of risk and severity of complications for the mother
and infant. This presentation will cover the challenges of dealing with the multidisciplinary care
of a pregnant woman with an implantable cardioverter defibrillator ICD pacemaker and neonate
with Tetrology of Fallot.

Case
A 41-year-old gravida 7, para 3 with a rare genetic disorder causing cardiac anomalies, NKX2.5
(otherwise known as the Tin Man gene), began
prenatal care at 16 weeks for an unplanned pregnancy with unknown last menstrual period. Maternal complications of pregnancy included severe
itching due to cholestasis, vaginal bleeding, and
suspected chronic abruption. A fetal echocardiogram at 24 weeks confirmed Tetrology of Fallot
with pericardial effusions. She was hospitalized for
vaginal bleeding at 32 weeks and again at 33 to
36 weeks gestation for vaginal bleeding, which

raised suspicions of chronic abruption. The patient was challenged by several test findings and
she struggled to trust herself as well as care
givers. The strong family history of varied cardiac anomalies increased her anxiety. Several social factors, marital discord, family dynamics, financial stress, and spiritual distress presented
unique challenges far exceeding the difficulty of
her physical management. The need for a holistic
approach to care for this patient and her family
became evident as well as the educational needs
of the staff caring for this family.

Conclusion
Regardless of specialty, nurses must be aware
of developing trends in all fields as multifactorial
complications present themselves in complex patients. Both maternal and neonatal complications
may be compounded by the physiological alterations and risks innate to pregnancy. As a trusted
resource and advocate, nurses must take a holistic
approach to care by identifying and providing the
necessary resources. The collaboration of varied
services and medical specialties was necessary
to provide consistent care, comfort and reassurance for this patient and her family. The teamwork
inspired staff to brainstorm and debrief, resulting
trust among caregivers and the patient and providing the basis for safe, compassionate care.

Maternal Over Fetal Health Chosen: A Case of Severe Lupus


Nephritis Remote From Viability
Stephanie Wyatt, MNSc, APN,
University of Arkansas for
Medical Sciences,
Little Rock, AR
Keywords
pregnancy
lupus
termination
grief

Childbearing
Poster Presentation

Background
ystemic lupus erythematosus (SLE) is an
autoimmune disease with serious consequences affecting mostly women with darker skin
at a rate 2 to 3 times greater than White women.
Management of lupus flares in pregnancy is challenging due to difficulty of the diagnosis and treatment limitations due to fetal effects. Severe flares
can cause damage to the maternal heart, lungs,
brain, and kidneys, requiring medications not acceptable in pregnancy due to teratogenic effects.
The mothers condition may deteriorate such that
birth is necessary despite the gestational age of
the fetus as illustrated in this case report.

JOGNN 2012; Vol. 41, Supplement 1

Case
The advanced practice nurse met Ms. AK in the
high-risk obstetric clinic at 7 weeks gestation.
She had a prior preterm delivery after a pregnancy complicated by SLE and pancreatitis. Despite 3 years of good health, she had 4+ proteinuria on dipstick but was otherwise asymptomatic
for lupus flare. By 11 weeks, she had 3 grams
of proteinuria, pitting edema, and suspected lupus nephritis. By 14 weeks, she had 7 grams of
proteinuria, and a renal biopsy confirmed Stage
IV lupus nephritis. At 15 weeks she had vaginal bleeding, hypertension, and a malar rash.
The fetus was growing well with a normal heart

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CASE STUDIES
Proceedings of the 2012 AWHONN Convention

rate but maternal ascites was noted. She began


inpatient management, had 13 grams of proteinuria, and on hospital day 6 elected for termination of pregnancy due to worsening renal disease
unresponsive to medical management. She was
scheduled for surgery but delivered vaginally after one dose of misoprostol. She initially declined
all bereavement activities but later asked to hold
the infant. She was discharged on hospital day
7 with follow-up in the nephrology, rheumatology,
and high-risk obstetric clinics. She was started
on lisinopril, mycophenolate, furosemide, and warfarin, medications not compatible with pregnancy.
At 4 weeks postpartum she was coping well and
elected for sterilization.

Conclusion
Termination of pregnancy is a complex decision
providing nurses a unique opportunity to help.
Women who terminate report feelings of guilt,
anger, and depression. They value nurses who exhibit caring through acknowledgement of grief and
individualized care. Nurses in this case lent support throughout the pregnancy and puerperium,
providing nonjudgmental, empathetic care with
continuous assessment of psychological health.
Collected mementos and time with the deceased
infant were encouraged as important activities in
the grieving process. At the postpartum visit, the
advanced practice nurse listened as the patient
described her experience, a vital intervention all
nurses can participate in.

Neurocysticercosis? How We Got There


Background
reeclampsia is a common diagnosis during
pregnancy. The symptoms of neurocysticercosis are similar to preeclampsia. A misdiagnosis
can be deadly for the mother and fetus. It is important for healthcare providers to recognize the
subtle differences and provide appropriate treatment.

Case
A 30-year-old gravida 1 at 22-weeks gestation was
admitted to the hospital for increasing nausea and
vomiting for the past 2 weeks. She had a four
pound weight loss since the beginning of her pregnancy. She stated she had a mild headache and
occasional white spots in vision. She had no other
complaints. Her vital signs on admission were temperature 98.1, blood pressure 111/61, pulse 71,
respirations 16, and fetal heart rate 140. Her physical exam was normal, and multiple laboratory tests
were ordered to rule out causes for hyperemesis.
Her laboratory values came back inclusive for
causes for hyperemesis or preeclampsia. Her
headaches and vision changes continued to
progress along with her nausea and vomiting. The
perinatology team ordered a computed tomography scan to assist in determining the cause for her
symptoms. The computed tomography showed
moderate hydrocephalus. The perinatology team
consulted with the neurologist. The neurologic

S176

exam found her pupils to be large but reactive.


Her speech was clear and she moved all four
extremities equally. The neurologist ordered magnetic resonance imaging to assist in determining
the cause for the hydrocephalus. The result of the
magnetic resonance imaging was a cystic mass
consistent with neurocystercosis.

Jennifer Truax, RNC, MSN,


Inova Fairfax Hospital, Falls
Church, VA
Martha Watson, RN, MSN,
Inova Fairfax Hospital, Falls
Church, VA
Keywords

This diagnosis brought a multidisciplinary team neurocysticercosis


preeclampsia
of perinatologists, neurosurgeon, neurologists, in- collaboration
fectious disease physician, and nursing together
to determine the best plan of care for this patient.
The patient was transferred to the neurologic intenChildbearing
sive care unit for closer monitoring with daily assessment of her fetus by the obstetric nurses. After Poster Presentation
much collaboration, the patient was treated to decrease the pressure of the hydrocephalus and kill
the parasite. The patient was transferred out of the
intensive care unit and eventually home. Due to
the patients psychosocial needs, case management was involved in assisting her transition to
discharge. The medications were costly and she
needed assistance to follow care.
Conclusion
Nursing was integral throughout this process. The
patient was concerned for her pregnancy. The obstetric nurses were able to focus on the needs of
her pregnancy and the neurologic nurses were
able to focus on her medical and neurologic
needs.

JOGNN, 41, S163-S188; 2012. DOI: 10.1111/j.1552-6909.2012.01363.x

http://jognn.awhonn.org

CASE STUDIES

Zauderer, C.

Proceedings of the 2012 AWHONN Convention

Brain Tumor in Pregnancy


Sheryl Dexter, RN, BSN, MSA, Background
Inova Fairfax Hospital, Falls
brain tumor is an extremely rare but serious
Church, VA

complication during pregnancy that jeopar-

Janet Hooper, RNC, BSN, MA, dizes the lives of the mother and fetus. There is
LCCE, Inova Fairfax Hospital
risk for significant morbidity or mortality. PhysioWomens Services, Falls
logic changes during pregnancy may worsen the
Church, VA
Keywords
lymphoma
brain tumor

Childbearing
Poster Presentation

neurological symptoms, have profound effect on


tumor growth, and affect the pharmacokinetics
of chemotherapeutic agents. Such changes include water retention, engorgement of vessels, increased plasma volume, third spacing in the amniotic fluid, and increased renal clearance and hepatic metabolism of drugs. The timing of chemotherapy, neurosurgical intervention, and birth should
be tailored to each patient. Concern for fetal outcomes while treating maternal cancer raises therapeutic, ethical, moral, and social dilemmas.

Case
We recently worked with a 38-year-old gravida 6,
para1 with a lymphoma metastasis to the brain.
On admission at 26 and 4 weeks gestation, she
was anemic from previous chemotherapy with
a hemoglobin of 11.3 and hematocrit of 33.8.
The fetal heart rate was 148. She presented with
an altered mental status, nausea, vomiting, dysnea, and had experienced a seizure at home.
Magnetic resonance imaging showed a herniated
large brain lymphoma with potential for rupture.

The significance of her worsening neurologic status resulted in a collaborative multidisciplinary approach to her care. The goal of medical management was to treat the cause, prevent further neurologic deterioration, provide supportive care, prolong the gestation, and maintain the well-being
of mother and fetus. Interventions included daily
rounds with the medical and nursing team to discuss the status of the mother and fetus. Ongoing
assessment and anticipation of the patients needs
were completed by the nurses. It was critical that
any change in her condition was evaluated for further progression of the disease. Dietary and psychosocial needs were also addressed. Extensive
counseling and planning are already occurring for
postpartum chemotherapy and/or surgery.
Conclusion
The diagnosis of a lymphoma brain tumor requires
planning for the anticipated birth and well-being of
the infant and long-term planning for the mother.
From this case we learned on the spot education for nursing and a multidisciplinary approach to
care. This included multiple physicians and representatives from nursing specialties, dietary, social
work, and case management meeting frequently
to discuss the latest condition of the patient. This
strong collegial relationship focused on the patients and infants welfare and well-being.

Eating Disorders and Pregnancy: Supporting the Anorexic


or Bulimic Expectant Mother
Cheryl Zauderer, PhD, CNM,
Background
NPP, New York Institute of
ating disorders in pregnancy have been asTechnology, Old Westbury, NY
Keywords
pregnancy
eating disorders
self-image
interdisciplinary approach

Childbearing
Poster Presentation

sociated with poor outcomes for the mother


and infant, including miscarriage/stillbirth, hypertension, cesarean birth, low birth weight, fetal
abnormalities, low Apgar scores, breech presentation, forceps delivery, cleft lip and palate, increased risk of bleeding during and after birth, and
healing problems after lacerations or episiotomy.
Women with a history of an eating disorder are
also at a higher risk for developing postpartum
depression.

Case
Felicia was diagnosed with anorexia nervosa during her teenage years. She stated that she could
not remember ever having a normal menstrual
cycle. Felicia claimed successful treatment for
anorexia nervosa after several years of therapy;
however, she still considered her relationship with
food somewhat stressful. Her weight was 110

JOGNN 2012; Vol. 41, Supplement 1

lbs, height 5 6 , and body mass index 17.8, which


is slightly below the recommended healthy body
mass index of 18.5 to 24.9. Despite attaining more
acceptable weight, her periods never returned.
Felicia turned to fertility specialists, and after 18
months she finally conceived.
Having the support of a therapist, a psychiatric nurse practitioner, a nutritionist and an understanding obstetric healthcare provider, Felicia
came to terms with her depression and symptomatology early enough. She had a recurrence during
the postpartum period. The interdisciplinary team
immediately worked on the depressive symptoms
surrounding her weight and worked on her diet
with her nutritionist. With the help of a lactation
support group, she was able to come to terms
with her body image and pregnancy weight. Her
self-esteem was restored, and she realized that
her eating disorder simply did not fit into her life
as a new mother with a new family.

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CASE STUDIES
Proceedings of the 2012 AWHONN Convention

Conclusion
Adjusting to pregnancy and motherhood can be
overwhelming. With the recent literature on the
negative effects of an eating disorder in pregnancy, there is an urgent need for nurses to
be aware of the signs and symptoms of an
eating disorder in the pregnant woman. Nurses

need to establish trust with the obstetric patient in order for her to be comfortable in disclosing the disorder. Once this occurs, they and
other healthcare professionals can lower risks
and enhance outcomes for mothers and infants vulnerable to negative effects of an eating
disorder.

25 Pounds and Counting: Binge-Eating Disorder


during Pregnancy
Background
esearch indicates that eating disorders are
one of the least likely psychological disorders
to receive adequate treatment, resulting in serious
consequences. The psychological treatment of individuals with eating disorders is a challenging endeavor, with many individuals lacking the motivation to change, thus requiring long term and costly
therapy. Individuals with binge eating disorder engage in the rapid consumption of a subjectively
large amount of food and experience feelings of
powerlessness when eating. Many binge eaters
report doing so to eliminate feelings associated
with anxiety, depression, and loss of control and
may also report low self-esteem and lack of selfawareness.

The hormonal changes associated with pregnancy often produce unstable emotions characterized by mood swings and feelings of despair.
Unwanted pregnancies cause an increase in anxiety, depression and feelings of powerlessness.
For individuals who have not developed effective coping strategies to deal with these emotional
shifts, previously or newly learned binging behaviors may emerge.
Case
A 38-year-old female, at 24 weeks gestation presented with a 35-pound weight gain and feelings of low self-esteem and guilt, complaining that

S178

she was ugly and fat. She had a questionable


history of obsessive-compulsive and anxiety disorders. Screening tools and therapeutic communication techniques were used to evaluate for anxiety, depression and eating disorders and revealed
binge eating disorder. This presentation will discuss screening tools to detect binge eating and
identify risk factors associated with binge eating
disorder. Information about referral, consultation
and interventional strategies (including therapeutic communication) will be discussed. Participants
will also be provided details that will be useful in
implementing a simple and cost affordable binge
eating disorder prevention program based on recent evidence-based literature.
Conclusion
Recently, a large, long-term study that examined
eating disorders in pregnant women revealed that
pregnancy may trigger the exacerbation or first
occurrence of binge eating disorder. Though the
adverse outcomes of binge eating disorder are still
not fully known, individuals with binge eating disorder may experience excessive weight gain and
obesity. Obese pregnant women have a greater
risk for pre-eclampsia, gestational diabetes, cesarean, and postpartum infection. Womens health
practitioners and midwives may lack the necessary screening, assessment and interventions
needed when caring for pregnant women with
binge eating disorder.

JOGNN, 41, S163-S188; 2012. DOI: 10.1111/j.1552-6909.2012.01363.x

Kristen Vandenberg, DNP,


FNP-BC, PMHNP-BC,
University of North Florida,
Saint Augustine, FL
Julie Baker-Townsend, MSN,
WHNP-BC, University of
North Florida, Saint Augustine,
FL
Keywords
binge-eating
eating disorder
pregnancy
anxiety
obsessive compulsive disorder

Childbearing
Poster Presentation

http://jognn.awhonn.org

CASE STUDIES

Bastianelli, K. S. and Henry, L.

Proceedings of the 2012 AWHONN Convention

Improving Breastfeeding Success: Nurses Commitment


to Evaluation of a Newborn Feeding at the Breast
Background
reastfeeding is the undisputed optimal feeding method for infants. In recognition of this
fact, Healthy People 2020 calls for an increase in
the number of mothers who have ever breastfed to
81.9%. However, the Centers for Disease Control
and Prevention reported this rate for 2011 as only
74.6%. To accomplish the Healthy People 2020
Debra A. Otto, RN, BSN, CCE,
goal, mothers need excellent breastfeeding supIBCLC, Christiana Care Health
port during the first few days of their infants lives.
Services, Newark, DE
The American Academy of Pediatrics 2005 PolKathryn E. Low, BSN, RN,
icy Statement recommended observation of feedCCE, IBCLC, Christiana Care
ings twice per day during the newborns hospital
Health Services, Newark, DE
stay.

Newborn
Care

Lydia Henry, MSN, RNC-OB,


CCE, IBCLC, Christiana Care
Health System, Newark, DE
Keywords
breastfeeding observation
breastfeeding assessment
latch

Poster Presentation

Case
Studies have shown an association between optimal feeds during initial hospital stay and longer
duration of breastfeeding. The new mother/baby
dyad often has difficulty in the first few days of
life in establishing breastfeeding. Continuation of
poor feeds can lead to a multitude of other breastfeeding problems that can ultimately lead to early
breastfeeding cessation. Observation and subsequent intervention can lead to better breastfeeding at discharge.
In a typical case, a first time mother told her nurse
that breastfeeding was going well. Two days after discharge, the mother returned for an outpatient lactation consult complaining of sore nipples

and decreased output from the infant. Upon observation, the lactation consultant noticed that the
infant had a shallow latch, was not transferring
milk well, and was causing nipple damage. The
lactation consultant corrected the positioning and
latch, resulting in immediate relief of pain. The lactation consultant was able to hear frequent swallows and the infant seemed satisfied afterwards.
Subsequently, the infant began having abundant
wet and dirty diapers and gained weight. If a feeding had been observed during admission, these
problems could have been resolved sooner. Many
mothers in this same situation would have stopped
breastfeeding. This mother can now successfully
breastfeed exclusively for 6 months and continue
breastfeeding for at least a year.
Conclusion
Mothers generally stay in the hospital from
48 hours to 96 hours postdelivery. During this
short time period, nurses often rely on mothers
self-report of breastfeeding sessions. Initially, the
mother may not be able to effectively determine
whether the feed is nutritive. Nurse observation
of breastfeeding during the hospital stay is imperative to ensure a successful start. While lactation consultants are experts, it is the postpartum
nurses who are key to around the clock observation and evaluation of breastfeeding. Observation
should include latch, positioning, and adequate
transfer of milk.

Variations in the Color of Breast Milk


Karen S. Bastianelli, RN, ADN, Background
IBCLC, CPCE, Christiana Care
reast milk is the optimal nutrition for newHealth System, Bear, DE
Lydia Henry, MSN, RNC-OB,
CCE, IBCLC, Christiana Care
Health System, Newark, DE
Keywords
breast milk color
breastfeeding
lactation
lactation support
breast assessment

Newborn Care
Poster Presentation

borns. When a variation in breast milk color


occurs, a lactating woman can become distressed
and abandon plans to breastfeed. Timely evaluation of milk can preserve breastfeeding and
as ensure the mothers health. As lactation consultants who are also registered nurses, the authors encounter many variations of color in breast
milk that have been determined to be normal.
Diet, medicine and breast health can contribute
to breast milks color. Appropriate assessments
aid in determining safety of breast milk and maternal health. Maternity nurses can renew their
commitment to breastfeeding support by becoming aware of variations, using a team approach
when needed, and offering emotional support to
affected women.

JOGNN 2012; Vol. 41, Supplement 1

Case
In one case, a primiparous woman with purple
milk required an interdisciplinary approach to determine the safety of her breast milk for her nearterm baby. Nipple discharge was noted in her second trimester of pregnancy and was monitored
without testing. The patient delivered at 35 weeks
gestation. To achieve a full milk supply, pumping was encouraged by the lactation consultant.
Pumping revealed an unusual purple color, and
the milk was withheld from the infant at the discretion of the postpartum nurse until the obstetric
resident could evaluate. A consult with the breast
surgeon was ordered, and the lactation consultant supported the decision and offered continued, daily guidance. An ultrasound revealed slight
ductal prominence in both breasts. A final consult
by the breast surgeon followed on day 4 at which

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CASE STUDIES
Proceedings of the 2012 AWHONN Convention

time the mothers milk was normal in color. The surgeon concluded the coloration was due to ectatic
ducts and hormonal stimulation. She encouraged
continued breastfeeding.
Conclusion
Emotional support from postpartum nurses who
are often first to notice a variation in the color of
maternal breast milk is imperative. Recognize that
mothers may experience high anxiety and disappointment if not able to accomplish breastfeed-

ing goalseven with only a short-term interruption of breastfeeding. Mothers may experience
stigma associated with unexpected variation of
breast milk color and increased anxiety when a
physician consult and/or testing becomes necessary. Reassurance may be necessary to support
mothers to use breast milk when it is an unusual
color. Lactation consultants are part of the team
that determines the course of action for mothers
with variations in breast milk color. They offer support to the mother and nursing staff.

Group B Streptococcus Sepsis: A Silent Sleeper


in the Neonatal Intensive Care Unit
Background
ne of every four or five pregnant women carries group B streptococcus (GBS) in her rectum or vagina. For the nonpregnant woman this
is little cause for concern, but it is well understood that GBS can have devastating effects during pregnancy for the mother and her newborn.
Nearly 75% of the cases of GBS infection among
newborns occur in the first week of life. Although
it is very rare, GBS infection may also develop in
infants 1 week to several months after birth. Meningitis is more common with late-onset GBS infection. The Centers for Disease Control and Prevention updated their prevention guidelines effective
in 2010.

Case
This poster presentation will provide a case study
of a 28 6/7 week gestation male twin who developed GBS meningitis on day 76 of life. This case
demonstrates the fragility of the neonatal intensive
care unit population even as infants are approaching discharge.

Virginia Long, CRNP, Saint


Vincent Health Center, Erie, PA
Rhonda Steigerwald, AD,
RNC, MHA, Saint Vincent
Health Center, Erie, PA

Keywords
GBS Infection
Conclusion
late-onset
Astute nurses in conjunction with the entire care sepsis

team must be vigilant in their assessments and


understand the potential risks, the importance of
timely recognition and intervention, and the impact
on the family. Nurses must remain cognizant of the
most current treatment guidelines.

Newborn Care
Poster Presentation

The Birth of Baby Will: Supporting a Devout Catholic


Couple through the Birth and Death of Their Anencephalic
Son
Background
nencephaly is one of the most common neural tube defects. It occurs early in the development of the unborn fetus when the neural tube
fails to close and may affect as many as 1 in 4,000
pregnancies per year. Because there is no treatment for this condition, which is catastrophic and
renders the infant without the possibility of ever
gaining consciousness, many women choose to
terminate the pregnancy when they receive the
diagnosis. However, for some women this is not
an option because of their religious beliefs. The
Catholic Church does not endorse termination and
supports carrying the fetus as close to term as is
possible without endangering the mother.

S180

Case
K.P. came to us for care during her fourth pregnancy, and we found that she was carrying an
anencephalic fetus. All of her previous children
were delivered via cesarean at our hospital, and
her physician urged her to terminate this pregnancy to spare her the possible dangers of another cesarean. She was unwilling to do this because of her faith and was praying for a miracle for
this child or at least that his life would be honored
no matter how short. She approached me about
the possibility of having her priest present at birth
to perform extreme unction and also requested to
be recovered in her hospital room so that her other
children and extended family could be present to
have whatever time possible with the infant.

JOGNN, 41, S163-S188; 2012. DOI: 10.1111/j.1552-6909.2012.01363.x

Ardath Youngblood, MN,


IBCLC, RNC-OB, Hunterdon
Medical Center, Flemington,
NJ
Keywords
anencephaly
bereavement
cultural sensitivity
Catholic

Newborn Care
Poster Presentation

http://jognn.awhonn.org

CASE STUDIES

Monangi, N.

Proceedings of the 2012 AWHONN Convention

Conclusion
Although some staff were distressed at the additional danger to the mother, there were those who
were glad to help support this family at this difficult
time. We worked with K.P. to meet her requests and

to make memories through photography, molds of


the infants feet, a lock of hair and foot prints. K.P.
has been able to move on from this experience
with the help of counseling and her faith community.

Caring for Simon: A Case Study in Care for an Infant


with Trisomy 18
Sheryl Crosier, MBA/MA,
Independent Business
Development Consultant, St.
Louis, MO
Deborah A. Bruns, PhD,
Southern Illinois University
Carbondale, Carbondale, IL
Sheryl Crosier, MBA/MA,
Independent Business
Development Consultant, St.
Louis, MO
Keywords
trisomy 18
NICU care team
cardiac anomalies
decision making
collaboration

Newborn Care
Poster Presentation

Background
esearchers describe the prognosis for newborns with full trisomy 18 as poor; only approximately 10% survive to their first birthdays.
Cause of death is usually related to complications
due to central apnea and/or cardiac anomalies
such as ventricular septal defect. Several recent
studies described medical interventions for surviving newborns, including provision of supplemental oxygen, continuous positive airway pressure,
and related mechanical ventilation. There needs
to be further examination of the care received
by newborns with full trisomy 18 during the prenatal, neonatal, and immediate perinatal periods.
Professionals must be aware of possible medical
complications as well as strategies to facilitate collaboration to ensure appropriate treatment decisions.

Case
Simon was born on September 7, 2010 at 38
weeks gestation. He weighed 1,900 grams and
presented with patent ductus arteriosus, ventricular septal defect, coarctation and a bilateral cleft
lip. He was diagnosed at 3 days with trisomy 18
and lived 88.5 days in the Level III neonatal intensive care unit of a mid-sized hospital in the
Midwest. Simons team of care providers included
neonatologists, a pediatric cardiologist, a pharmacist, nurses, and respiratory therapists. This group
worked closely with Simons parents to make treat-

ment decisions (e.g., prostaglandins, insertion of


a peripherally inserted central catheter) and manage daily care such as feeding and bathing. Most
decisions were made collaboratively. When disagreements occurred, often due to his diagnosis,
the majority of Simons nurses honored his parents preferences. Nurses also provided support
and information to Simons parents and his older
brothers (aged 7 and 5).
Initially, Simon was a candidate for heart surgery
but respiratory complications delayed development of a plan until close to the time of his death.
Apnea episodes became frequent and decisions
were made to the optimal method of response.
Simons parents repeatedly voiced their objections to the types of interventions during apnea
episodes. Several times, for example, Simons father objected to having him bagged and preferred for Simon to come back around. They also
advocated introducing tastes of breast milk, which
Simon enjoyed. He also was fond of bath time with
his brothers, and he communicated these emotions through gaze and facial expressions.
Conclusion
Simons life offers implications for nursing practice
including blending medical treatments and familycentered care in the face of a bleak diagnosis.
There is a need for care that is professional and
compassionate regardless of diagnosis.

Congenital Chylothorax
Nagendra Monangi, MD,
Background
Cincinnati Childrens Hospital
hylothorax is caused by chyle containing
Medical Center, Cincinnati, OH

Keywords
chylothorax
octreotide
pleural fluid
chest tube

Newborn Care
Poster Presentation

lymphatic fluid draining into the pleural cavity. Chylothorax is the most common type of pleural
effusion during the neonatal period, may cause
significant respiratory compromise, and is associated with substantial mortality and morbidity.
This report summarizes the course of a 35 weekgestation neonate with bilateral congenital chylothorax with a review of etiology, radiographic
and laboratory diagnosis, and successful management of chylothorax with octreotide.

JOGNN 2012; Vol. 41, Supplement 1

Case
A preterm male infant was born weighing 4,695
grams at 35 weeks gestation to a 33-year-old
mother by cesarean due to weight gain of 20
pounds in 2 weeks, limb edema, hypertension,
polyhydramnios, fetal distress, and face presentation. There was no significant maternal medical history and 8 and 20 weeks gestation ultrasounds were reported as normal. Resuscitation at
delivery included intubation with assisted ventilation, placement of umbilical lines, and intratracheal epinephrine and surfactant. Apgar scores

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CASE STUDIES
Proceedings of the 2012 AWHONN Convention

were documented as 0, 1, 3, 7 at 1, 5, 10, and 15


min. A chest radiograph revealed complete whiteout suggestive of massive pleural effusions and
bilateral chest tube placements produced 200 ml
of straw-colored pleural fluid.

ued on day 30. Slowly advancing feedings with a


protein-vitamin-mineral formula were commenced
on day 4 of octreotide. The infant was fully bottle
and breast fed with resolution of chylothorax and
respiratory distress on day 40.

Composition of pleural fluid with predominance of


lymphocytes and chylomicrons with no evidence
of infections, genetic or metabolic anamolies and
cardiac disease suggested congenital chylothorax. Chest tube output initially went up to a maximum of 900 ml/day and dropped slowly to 300
ml/day by day 10. The patient was extubated on
day 11 but continued to put out 200 to 300 ml/day
of chyle requiring the chest tubes to be left in situ.
Octreotide was administered intravenously initially
at 1 mcg/kg/hr titrating to a maximum dose of 7
mcg/kg/hr from days 23 to 32. With octreotide,
chest tube output dropped significantly with no
side effects and both chest tubes were discontin-

Conclusion
Congenital chylothorax, an uncommon cause of
respiratory distress in neonates, is diagnosed initially by prenatal ultrasound or postnatal x-ray and
definitely by evaluation of pleural fluid in the pleural space. Standard management of neonatal chylothorax usually entails prolonged hospitalization
requiring multiple procedural or surgical interventions. Nutritional status, along with fluid and electrolytes, needs to be monitored closely. Administration of octreotide in our case led to a more rapid
resolution of pleural drainage, no recurrence, and
early hospital discharge.

Implementation of an Obstetric Hemorrhage Protocol


Outside the Obstetric Department
Background
bstetric hemorrhage is a significant cause
of maternal morbidity and mortality. Early
recognition and prompt intervention are keys to
minimizing complications. The rate of maternal
deaths in the United States has nearly doubled
from 7.6 per 100,000 in 1996 to 13.3 per 100,000
annual births in 2006. However in California the
Connie von Kohler, RNC,
rate of maternal deaths has nearly tripled from
MSN, CPHQ, Miller Childrens
6 per 100,000 in 1996 to 17 per 100,000 annual
Hospital, Long Beach
births in 2006. What is particularly troubling about
Memorial Medical Center,
both of these trends is the fact that the worldwide
Long Beach, CA
maternal mortality rate had decreased during this
Keywords
same time. This troubling statistic served as the
hemorrhage
impetus to develop the California Maternal Quality
antepartum
Care Collaborative to end preventable maternal
Paper Presentation death and injury and to promote equitable maternity care in California. Miller Childrens Hospital Labor and Delivery joined a quality improvement collaborative through the California Maternal
Quality Care Collaborative to develop an obstetric
hemorrhage protocol.

Professional
Issues

Case
Women in early pregnancy, before 20 weeks gestation are often triaged and treated in the main hos-

S182

pital emergency room when presenting for bleeding or threatened spontaneous abortion. This was
true in the case of a young woman at 14 weeks
gestation. Early antepartum hemorrhage (before
20 weeks gestation) can be caused by abortion/miscarriage, ectopic pregnancy, or gestational trophoblastic disease. Early diagnosis and
treatment is essential and often not done urgently
or with the thought of life threatening hemorrhage.
Deterioration can happen suddenly, and underestimation of blood loss and misleading maternal
response can mask the need for an urgent response. The patient may maintain a normal blood
pressure until sudden and catastrophic decompensation occurs. It is essential that the team in
any setting knows how to respond quickly and appropriately as time is of the essence.
Conclusion
A well-coordinated team can mean the difference
between life and death. In this case, the resident initiated the obstetric hemorrhage protocol
and saved this womans life. After the episode, the
team debrief reinforced the importance of quantifiable blood loss education as well as the implementation of the obstetric hemorrhage protocol.

JOGNN, 41, S163-S188; 2012. DOI: 10.1111/j.1552-6909.2012.01363.x

http://jognn.awhonn.org

CASE STUDIES

Pickerel, A. D.

Proceedings of the 2012 AWHONN Convention

Mountains to Climb: Changing National Policy on College


Athlete Pregnancy
Elizabeth A. Sorensen, PhD,
RN, CNOR, Otterbein
University, Westerville, OH
Keywords
college athletes
Title IX
NCAA guidelines

Professional Issues
Paper Presentation

Background
urses are committed to all aspects of
womens health. Although Title IX has prohibited pregnancy discrimination since 1976, discriminatory practices in college athletics continue to include removing pregnant athletes scholarships and athletic participation, requiring female athletes to sign statements that they will
not get pregnant, and shaming pregnant athletes.
These practices create unsafe health environments, which motivate pregnant college athletes
to conceal their pregnancies and worse. In 2007
two college freshmen athletes killed their term infants after delivering in their dorm rooms.

Case
This session summarizes knowledge on intense
exercise during pregnancy and chronicles one
nurses 5-year advocacy for womens health by
changing the National Collegiate Athletic Associations (NCAA) policies on pregnancy. The new
NCAAs guidelines, co-authored by the presenter
and distributed to all NCAA schools, generally protect pregnant athletes scholarships, inform athletes and athletic administrators about safe athletic participation during pregnancy, and create
a safer environment for pregnant athletes to reveal pregnancy and seek health care. Yet the
process remains imperfect. For example, institutions that view pregnancy as a violation of stu-

dent conduct are still permitted to revoke pregnant athletes scholarships. Pregnant individuals
who self-identify (following the new NCAA guidelines) may not realize that they are inviting these
consequences. The NCAA continues to deny new
fathers time away from athletics needed to parent.
The new NCAA guidelines do not carry the authority of bylaws and do not require reinstatement as
Title IX directs.
Title IX, case studies, current research on intense
exercise during pregnancy, and the new NCAA
guidelines will be reviewed to ignite participants
passions to improve outcomes in this vulnerable
population. Pregnancy issues unique to competitive athletes will be presented including the male
model of competitive sports, the culture of risk
which encourages athletes to deny pain and injuries in order to continue competing, pregnancy
as a crisis, and a widespread myth that pregnancy
enhances athletic performance and is a form of illegal blood doping.
Implications for Practice
Recommendations for new directions in nursing research and advocacy will include
nursing research focused on this unstudied
population, breastfeeding in new college athlete mothers, male athletes who father children
during college, high school athletes, and athletes
at faith-based schools.

5 Alive, Postpartum Hemorrhage 0: One Nurses Journey


Angela D. Pickerel, BSN, RN,
RNC-OB, Poudre Valley
Hospital, Fort Collins, CO
Keywords
communication
collaborative
organization
OB severe hemorrhage

Professional Issues
Poster Presentation

Background
nitially, two cases of severe obstetric hemorrhage were evaluated to assess current practice
related to obstetric hemorrhage policies. Staff education and practice changes were implemented.
Two additional cases occurred, which allowed another opportunity to assess for improvement in
nursing/collaborative care implementation. During these additional emergency situations, the response of staff and collaborative team members
was evaluated based on the previous clinical recommendations. The final case review is an outlying
case involving multiple nursing units. The severe
obstetric hemorrhage occurred six hours after delivery on a postpartum unit.

Case
All cases involved initiation of the obstetric Severe Hemorrhage Policy, which is initiated at the

JOGNN 2012; Vol. 41, Supplement 1

request of the obstetric provider. Cases were evaluated for risk factors of postpartum hemorrhage.
Lab results at admissions, during hemorrhage,
and until discharge were assessed for quantification of blood loss versus the stated estimated
blood loss. Cases were also evaluated for timeframe recognition of postpartum hemorrhage to
initiation of the obstetric Severe Hemorrhage Policy. The policy activates collaborative team members including obstetrics, anesthesia, labor and
delivery nursing, intensive care unit resource nursing, nursing supervisor, and laboratory/blood bank
personnel. Cases were reviewed for pharmacologic and nonpharmacologic interventions prior
to any need for surgical interventions as well as
resuscitative measures during interventions. Also
evaluated was the response timeframe for collaborative team members including laboratory, blood
bank, and radiology.

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CASE STUDIES
Proceedings of the 2012 AWHONN Convention

Conclusion
After completion of the first two case reviews,
recommendations for nursing were brought to labor and delivery clinical practice. Emphasis was
placed on encouraging direct, focused, and early
communication with providers and collaborative
team members and working to quantify blood loss
early in hemorrhage to allow for quicker decision in
initiation of multidisciplinary services in policy. Additional recommendations included improved role
management; communication through centralized
location; organization of quick reference checklist
and nursing documentation worksheets for better
capture of event time lines; and implementation

of obstetric Severe Hemorrhage Cart with determination of centralized location of cart for rapid
access to equipment. The obstetric Severe Hemorrhage Cart is assessable to obstetric focused
nursing units.
It is significant to note that the same nurse was in
attendance for each case, which allowed for critical analysis of practice, focused implementation
of practice changes, and real-time evaluation. Significant decrease in timeframe from recognition of
hemorrhage to actual initiation of policy occurred.
Communication significantly improved resulting in
increased safety for patients and satisfaction from
team members involved.

Surrogacy: Policy Development is Required for the Real


Parents to Stand Up
Background
he practice of surrogacy is becoming increasingly prevalent in the United States. Data currently available from the Centers for Disease Control and Prevention and the Society for Assisted
Reproductive Technology demonstrate the number of infants born to gestational surrogates has
almost doubled from 2004 to 2008, from 738 infants to nearly 1,400. The growth of surrogacy
will result in multiple implications for nursing practice. To effectively manage patients and those
involved in the surrogacy situation, policy development and subsequent education are imperative. Furthermore, multidisciplinary collaboration is necessary to achieve optimal nursing
practice.

Case
A 36-year-old gravida 6, para 4 at 28 weeks gestation with twins, presented to labor and delivery.
Her previous history included a successful surrogate pregnancy and delivery. The patient reported
this was also a surrogate pregnancy, and the biologic fathers lived in France. The patient was
supported by her husband and tocolytics were
attempted without success. The patient delivered
via cesarean, and the twins were admitted to the
Level III neonatal intensive care unit. No docu-

S184

mentation related to this surrogacy was available


for 2 days. The nursing staff was confused and
unsure of what was legally appropriate and tried
desperately to figure out the right thing to do.
By day 3, the judgment documents arrived via
certified mail from the attorney representing the fathers, who were named as the biologic and legal
parents. Subsequently, the judgment relinquished
all rights of the patient regarding the twins. The
fathers arrived late on day 3. The patient was then
denied visitation and later filed a complaint related
to this decision. The two fathers stayed at a local
hotel, eventually returning to France with their new
son and daughter.

Conclusion
As a result of changing family dynamics and the
growing field of reproductive technology, surrogacy cases will continue to increase in the hospital setting. This case study illustrates the need
for a hospital policy to effectively provide optimal
care. It is vital to understand terminology as it relates to the parents involved. In addition, current
state law as it pertains to surrogacy must be incorporated. Finally, true success resulting in positive
outcomes for the surrogacy situation requires multidisciplinary support and education.

JOGNN, 41, S163-S188; 2012. DOI: 10.1111/j.1552-6909.2012.01363.x

Lori J. Bacsalmasi, MSN,


RNC-OB, CCE, Providence
Saint Joseph Medical Center,
Burbank, CA
Dawn Hernandez, BSN,
NE-BC, RNC-OB, PHN,
Providence Saint Joseph
Medical Center, Burbank, CA
Keywords
surrogate
intended parents
judgment of maternity and
paternity

Professional Issues
Poster Presentation

http://jognn.awhonn.org

CASE STUDIES

Smithgall, L.

Proceedings of the 2012 AWHONN Convention

Its a Recession: Implications for the Underinsured


Antenatal Patient
Pamela Braithwaite, BSN,
RNC, Christiana Care Health
System, Bear, DE
Adeyinka O. Reid, BA, BSN,
RNC, Christiana Care Health
System, De, DE
Keywords
uninsured
perinatal
hardship
complications
recession

Professional Issues
Poster Presentation

Background
he current economic recession in the United
States has had a profound impact on the nation healthcare system. One specific population at
risk is the pregnant woman and their infants. The
American College of Obstetricians and Gynecologists reported that uninsured pregnant women
are more likely to experience an adverse maternal
outcome. Uninsured newborns are more likely to
experience adverse health outcome and are more
likely to die than insured newborns. It has been
reported that 18% of uninsured pregnant women
have reported that they did not receive needed
medical care versus 7.6% of privately insured
and 8.1% of Medicaid-enrolled pregnant women.
These uninsured women face barriers such as access to healthcare providers, diagnostic testing,
and alternate insurance coverage.

Case
A 39-year-old gravida 2, para 0100 was seen in the
emergency room prior to delivery and diagnosed
with kidney stones. During that visit, she was found
to be 23 weeks pregnant with elevated blood pressure and blood glucose. She stated that she was
unable to obtain her medications due to a lack of
health insurance, secondary to her spouse losing

his job. Also, due to lack of insurance she was


able to attend only one prenatal visit. At 25 weeks
gestation she presented to the emergency room
with reported tonic/clonic seizures. Upon admission to a prenatal special care unit, complications
included advanced maternal age, morbid obesity,
insulin dependent diabetes, chronic hypertension,
undiagnosed sleep apnea, and preterm delivery.
Due to elevated blood pressures and recurrent
eclamptic seizures, the decision was made to
deliver by repeat cesarean a baby boy who died
145 days following delivery.
Conclusion
The presentation will include the need for early
identification of potential barriers to adequate prenatal care to achieve the best maternal-fetal outcome. Healthcare providers are a crucial source
of on-site or referral support services to buffer the
health-damaging effects of hardship on women
and children. It is important to offer information on
national and state programs such as Medicaid,
community programs like Healthy Beginnings (in
Delaware), health care discounted programs, and
free clinics. A multidisciplinary healthcare team
approach can optimize perinatal outcome in this
population.

Closure of an Obstetric/Newborn Service in a Rural


Community Hospital: Implementation of a Plan for Prenatal
Care Access, Obstetric Triage, and Transition to a Birth
Facility
Lisa Smithgall, PhD, RNC,
Background
CPNP, NEA-BC, Mountain
he provision of obstetric and newborn care is
States Health Alliance, Johnson
often considered a basic service in a commuCity, TN

Keywords
obstetrics program closure
prenatal care
care transition

Professional Issues
Poster Presentation

nity hospital. In rural communities with low birth


volumes, multiple challenges exist for the delivery of a quality health care obstetric and newborn
service. Acquiring and maintaining sufficient,
skilled specialty resources for the delivery of high
risk low volume obstetric care presents the opportunity for risk to safety and the potential for
negative clinical and quality outcomes. Financial
implications must also be considered in the evaluation of maintaining an obstetric/newborn service
in a rural community hospital.

JOGNN 2012; Vol. 41, Supplement 1

Case
The decrease in the population of child bearing
age women in the region, reduced number of
births, increased costs associated with minimum
staffing of multiple interdisciplinary resources for
the provision of the obstetric service, and the
losses related to increased Medicaid covered patients justified the need for a thorough assessment
and evaluation of the inpatient obstetric/newborn
service and the subsequent decision for service
closure. Planning and implementation for the closure of the inpatient obstetric/newborn service
in a rural community hospital presented multiple opportunities and challenges for the nursing
leadership team. The communication plan regarding service closure and education regarding the
plan for care for obstetric patients after service

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CASE STUDIES
Proceedings of the 2012 AWHONN Convention

closure was identified for the community, health


care providers, and current obstetric patients receiving care. Triage assessment, birth, and emergency care procedures for obstetric related health
care issues were identified with education completed for nursing and interdisciplinary emergency department team members to ensure competency and standard of care delivery for the obstetric and newborn patient population. A coordinated plan for obstetric care was identified with
the rural community and birth facility nursing and
physician team members to assure access to prenatal care close to home early in pregnancy and
the successful transition of the obstetric patient

and her health information to the birth physician


and birth facility in the third trimester.
Conclusion
The closure of the obstetric/newborn unit was an
emotional issue for the community with the originally defined plans for post-closure obstetric care
requiring multiple revisions to achieve the desired
provision of obstetric care for prenatal care access, appropriate emergency care for obstetric
issues at the rural community hospital, and transition of patients to the provider and facility for labor
and birth. Nurses have a key role as advocates for
obstetric patients navigating care across a multifaceted continuum for service.

Expecting the Unexpected: Proactive Planning for Massive


Obstetric Hemorrhage
Background
emorrhage is one of the leading causes of
maternal death in the United States, and
massive hemorrhage occurs in an approximate 1
to 2% of all births. Patient status can turn critical in a matter of seconds. Risk factors, both
known and unknown, complicate the clinical picture of the patient, leaving her at risk for an unexpected outcome and the obstetric emergency
of either intrapartum or postpartum hemorrhage.
While advanced maternal age, maternal obesity,
fetal macrosomia, and prolonged labor are risk
factors contributing to maternal hemorrhage, it is
the complications of pregnancy that place the patient at increased risk of massive obstetric hemorrhage. These complications include, but are
not limited to, accreta, percreta, increta, placental abruption, placenta previa, development of
HELLP syndrome, and disseminated intravascular
coagulation. These conditions place the patient at
risk for a life threatening sequelae of events. In
these situations, effective hemodynamic management of the patient is a priority.

Evidence identifies the best management for complications such as these begin with a multidisciplinary team approach. Inclusion of nursing staff,
physicians, anesthesia, transfusion services, laboratory, hematology, respiratory therapy, and administration is necessary for optimal patient outcomes.

S186

Case
The development of a Massive Obstetric Transfusion protocol was initiated at Baylor All Saints
Andrews Womens Hospital to promote better patient outcomes for the pregnant population experiencing a life threatening hemorrhage at or following birth of an infant. This protocol allows for
proactive, interdisciplinary dynamics, and collaboration for planning patient care, not only when risk
factors are present before birth, but also when a
hemorrhage occurs unexpectedly.
The initial implementation occurred in July 2010
in response to an inpatient with multiple risk factors and diagnosed with percreta placental abnormality. We will present a case study of the scenario that unfolded, ultimately ending in a positive outcome for the patient. Additionally, we will
highlight case specifics of a second patient with
similar risks that did not accept blood products.
Options for this patient population will also be
discussed.

Dara N. Lankford, BSN, RNC,


Baylor Health Care System,
Rhome, TX
Stephenie Akins, MS, RNC,
Baylor Health Care System,
Rhome, TX
Keywords
hemorrhage
transfusion
emergency
life-threatening

Professional Issues
Poster Presentation

Conclusion
Through collaborative efforts of all members of
the healthcare team using evidence-based practice, this protocol was successfully implemented
in a controlled situation. With lessons learned,
this protocol can be used when planned and
unplanned cases arise to foster positive patient
outcomes for patients experiencing massive OB
hemorrhage.

JOGNN, 41, S163-S188; 2012. DOI: 10.1111/j.1552-6909.2012.01363.x

http://jognn.awhonn.org

CASE STUDIES

Morgan, Q. E.

Proceedings of the 2012 AWHONN Convention

How a Magnet Hospital Handles a Crisis at 0230:


Spontaneous Coronary Artery Dissection
Background
pontaneous coronary artery dissection was
first described in 1931, and since then fewer
than 350 cases have been documented. A sigKeywords
Magnet model
nificant number of spontaneous coronary artery
exemplary professional practice dissections present as sudden death with many
new knowledge-innovationscases only being diagnosed at autopsy. As an
improvements
American Nurses Credentialing Center Magnet
spontaneous coronary artery
designated hospital, this organization demondissection
strates the expertise of nursing care through exemplary professional practice and new knowlProfessional Issues edge and innovations and improvements. These
are just two of the components of Magnet status
Poster Presentation that are engrained in the nursing care at this community hospital.

obstetric first responder program, which was immediately activated. Further evaluation involved a
cardiac catheterization, which diagnosed a spontaneous coronary artery dissection. A team of
nurses, ancillary staff, and physicians met to formulate a plan for delivery of the fetus and care
of the mother. What began as a visit to the
triage area of a community emergency room at
0230 resulted in a term, male infant admitted
to the well-baby nursery following a successful
transition period. The mother was transferred to
the intensive care unit on a ventilator following
surgery. The mother and infant were discharged 5
days after major cardiac surgery following a rare
disease.

Case
A 32-year-old gravida 2, para 1 Hispanic women
presented with a chief complaint of chest pain.
She was immediately seen by a triage nurse who
recognized the critical situation and activated the
cardiac alert algorithm. This allowed her to obtain an electrocardiogram, immediately bypass
triage, and obtain care by an emergency physician. With the information provided, it was suspected that the patient was experiencing an acute
myocardial infarction. This hospital also has an

Conclusion
The culture of nursing care and collaborative practice model allowed a multidisciplinary group of
staff to come together to provide life-saving care to
a mother and her infant. This represented a successful outcome to a rare and often fatal occurrence. Through transformational leadership and
structural empowerment nurses are encouraged
to make decisions based on what is best for patients and implement algorithms and protocols
based on their nursing assessment.

Neva J. Spencer, MSN,


NNP-BC/CNS, The Medical
Center of Aurora, Aurora, CO

Cesarean Birth: Transforming an Intensive Care Room Into


an Operating Room
Quin Elizabeth Morgan, RN,
BSN, Long Beach Memorial,
Downey, CA
Keywords
assessment
teamwork
communication
coordination
aseptic technique

Professional Issues
Poster Presentation

Background
s nurses, often we are faced with many amazing challenges that cause us to be stronger
or allow us to grow. In my presentation I will discuss the importance of teamwork and collaboration between obstetric nurses and intensive care
unit nurses and physicians. Through this collaboration and effective communication we were able
to transform the intensive care unit into a working
operating room.

Case
A 29-year-old female at 30 weeks gestation was
transferred to our hospital in critical condition.
She presented with acute respiratory distress syndrome and was hypotensive. She arrived intubated and in an induced coma. Prior to arriving
in intensive care unit, I was given a report by
my coordinator and asked to run a fetal strip and
assess the current situation. When I arrived the

JOGNN 2012; Vol. 41, Supplement 1

patient was in atrial fibrillation. I then contacted


my coordinator and discussed the critical nature
of the patients condition. My coordinator called
perinatology to the intensive care unit room, and
within the hour a decision was made to perform an
emergent cesarean in the intensive care unit. At
this point we were supporting the patients blood
pressure and oxygenation.
The staff and I had to act with haste. I called my coordinator, gave her a report, and told her I needed
another staff member. I then observed and assessed the size of the intensive care unit and its
cleanliness, and I began to clean and wipe the
main counter top attempting to maintain aseptic
technique. Both the primary intensive care unit
nurse and I started cleaning the overall environment. Another nurse and an obstetric technician
arrived to assist with the transfer of items in the
operating room to the intensive care unit.

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CASE STUDIES
Proceedings of the 2012 AWHONN Convention

Conclusion
After an anesthesiologist arrived, coordination between me and the intensive care unit nurses and
staff was vital. We accumulated supplies from the
womens operating room and intensive care unit.
We discussed needs for maintaining sterile tech-

nique and went over the cesarean procedure in


our minds. Representatives from the neonatal intensive care unit arrived, and we located an appropriate room to resuscitate the infant at birth.
Through effective communication and collaboration we performed a successful cesarean.

Neonatal Intensive Care Unit Rapid Design Process


Background
e discuss the rapid design process for
neonatal intensive care unit (NICU) space
development and implementation using principles
from Lean, six sigma, change theory, and structured communication.

Case
The rapid design process of a level III NICU had
mutual goals and benefits with considerable constraints. Most importantly, providing a local space
for NICU families would result in healthier families
and better outcomes for the patients of the region.
Previously NICU or antenatal patients would be
flown out of state for a higher level of perinatal
care services. Each stakeholder had competing
and complementary priorities that all needed to
be captured and expressed in an efficient and effective way for patient care as well as process.
A purist type of design did not develop due to
multiple demands and constraints; rather a hybrid
evolved out of focus groups, site visits, and a literature review. The design elements of the four seasons paired with materials from nature resulted
in an environment that was both welcoming and
functional. The best elements of each type of NICU

S188

layout were selected to give the best outcomes for


patients, families, and the healthcare team. Despite the application of structured communication
methods, shared governance, Lean and six sigma
concepts, lessons were revealed at every step of
the process. Each dedicated decision was centered around the patient and the family, now and
for the future. Satisfaction with the space postoccupation varies positively and variably as other
studies have revealed. Other intended outcomes
of the space design were that the space would
positively result in shared learning of staff and promote nurseparent closeness.

Conclusion
Communication and site visits increased all parties understanding of the space design, function,
flow, efficiency, and patient and family outcomes.
Intended outcomes of the space were increased
team satisfaction with flow and function as well
as collaboration with novice and experts within
the staffing mix. The space lends itself to privacy
as well as accessibility of staff by families. The
semi-open space allows for families to interact and
come together to support each other.

JOGNN, 41, S163-S188; 2012. DOI: 10.1111/j.1552-6909.2012.01363.x

Patricia Anderson, RN, MBA,


Eastern Idaho Regional
Medical Center, Idaho Falls, ID
Dixie K. Weber, MS, RNC,
Eastern Idaho Regional
Medical Center, Idaho Falls, ID
Keywords
NICU design
healthcare economics
rapid design process
structured communication
methods

Professional Issues
Poster Presentation

http://jognn.awhonn.org

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