24 HOUR CARE PLAN

ON
MRS subha zehra w/o MR mohd
yaseen

A CASE OF
Primigravida at 38+3 weeks POG
with Rh-ve pregnancy

SUBMITTED TO SUMBITTED BY

MADAM MRS SMITHA MS. ANURADHA

ASSISTANT PROFESSOR MSc. NURSING 1ST YEAR

HFCON HFCON
 IDENTIFICATION DATA
Name of the patient : Mrs Subha zehra
Age : 20 years
Husband’s name : Mr Mohd Yaseen
I.P.D. no. : 19/020112
Ward no. /bed no. : labor ward. General room/ bed no-
Date of admission : 22/9/19
Educational status : Graduated
Occupation of mother : currently not working
Occupation of Husband : Private Job
Religion : Islam
Diagnosis : Primigravida at 38 weeks + 3 days with Rh negative pregnancy
Date of delivery : 23/9/19
Duration of marriage : 9 months
Address : B-188, Mohan Baba Nagar, Badarpur, New Delhi.
Doctor incharge : Dr Rashmi
Date of care started : 23/9/19
Date of discharge : not yet planned
ADMISSION HISTORY
CHIEF COMPLAINTS ON ADMISSION
Mrs Subra Zehra w/o Mr Mohd Yaseen 20 year female Primigravida 38+ 3 weeks of period of
gestation with Rh-ve pregnancy admitted on 22/9/19 at 11:35 pm with complaints of
 Amenorrhea since 9 months
 Pain in abdomen since 3 Hour.
 Bleeding per vagina since morning
ON EXAMINATION
 General condition is fair
 Patient is afebrile
 Oedema absent
 Pallor present
 Pulse: 102/mt
 BP: 120/80mm/hg
 Chest/CVS- NAD
  Per Abdomen- Cephalic presentation, ROA, FHR- 140/mt with Doppler. Mild uterine
contraction present.
 Vaginal Examination: OS admitting 1 finger cervix uneffaced, vertex at brim. Pelvic
adequate, membrane ruptured.
HISTORY OF PRESENT PREGNANCY
 Mrs subha zehra w.o mohd yaseen has spontaneous conception and detected by UPT then
confirmed by USG
Trimester 1
 All antenatal visit and check was done in holy family hospital
 Tab Folic Acid 5 mg treatment taken.
 No history of BPV present, hospitalisation, radiation exposure, drug exposure
 Having c/o of nausea and vomiting

Trimester 2
 Nausea vomiting continued.
 Quickening felt at 5 months.
 Received 2 doses of TT injection.
 Regular intake of Iron and calcium supplementation.
 No history of raised BP, pedal edema, blurred vision, headache , epigastric pain.
 No history of BPV and LPV present.
 Increased blood sugar level was there which get manages automatically by diabetic diet.
 Took Anti D on 20/8/19

Trimester 3
 Iron and calcium supplementation continued.
 No history of BPV, seizures.
 Having complain of fatigue.
OBSTETRICAL HISTORY
 Primigravida G(1)P(0)L(0)A(0)
 Period of gestation in week is 38 weeks plus 3 days.
PAST MENSTURAL HISTORY
 LMP: 17/12/18
 EDD: 24/9/19 by naegele’s formula
 Cycle: irregular due to PCOD later after treatment it was 4-5 days/30days
 Dysmenorrhoea: absent
PAST MEDICAL HISTORY
 No past medical history
SURGICAL HISTORY
 No history of any past surgery
HISTORY OF BLOOD TRANSFUSION
  No history of blood transfusion.
FAMILY HISTORY
 Living in joint family
 There are 8 members in her house.
 No history of congenital anomalies present.
 No significant family history of any hereditary illness in family.
 No history of chronic illness and mental illness present

PERSONAL HISTORY
 she is non vegetarian.
 Non-smoker, non-alcoholic, non-addicted to any drug,
 Personal hygiene is self-maintained.
 Bowel and bladder movements are normal.
 Normal sleep pattern (7-8hrs/day)
SOCIO – ECONOMIC DATA
 Type of family- nuclear.
 Number of family member: 8
 House: lives in rented house in Badarpur, Delhi. With proper ventilation
 Number of room in house is 3 with 2 wash rooms and 1 kitchen
 Electricity: available
 Bathroom and toilet facility: both are separately present at their home,
 Drainage: drainage system is closed.
 They discard their waste properly in MCD garbage vans.
 Mrs Subha is homemaker and her husband is having private job with salary of rupees 40000/-
. There is no financial crisis.
PHYSICAL ASSESSMENT
General assessment
 Height – 160cm
 Weight – 64.7 kg
  Posture- normal
 Nourishment- well nourished
 Grooming- well groomed
Vital signs
 Temperature: 97.2F
 Pulse- 86/mt
 Respiration rate- 22beats /mt
 Blood pressure- 110/70mm/Hg
 Spo2- 97% in room air
Head to toe examination
Hair is evenly distributed on head
Scalp is free of pediculosis no presence of dandruff over the scalp.
Head of the patient is round and symmetrical in shape
Eyebrow: eyebrow hairs are evenly distributed the client eyebrows are symmetrically distributed
and
Eyelashes: eyelashes appears to be equally distributed and black in color.
Conjunctiva appear pink in color.
Sclera is transparent and shinny.
Pupils are black and equal in size they are equally reactive to light. No discharge present from eyes.
External ear the auricles are symmetrical and has same colour with the facial skin the auricles are
aligned with outer canthus of the eye when palpating for texture the auricles are mobile firm and
non-tender.
Tympanic membrane there is no presence of perforation or discharge. Hearing sense in present
Nose
 Nose appeared symmetrical straight and uniform in color.
 No discharge for nose
 Mucous membranes: the mucous membrane is pink in color but appeared dry
 The nasal septum patient has straight nasal septum no deviation is found
Mouth
Lips the lips of the mother is pink.
Gums absent of bleeding and gingivitis.
Teeth clean and white and 32 in number
Tongue the tongue of the client is centrally positioned and pink in colour
Oral mucus is intact.
Lymph nodes of the client are not palpable
Patient is having endotracheal tube and airway going through mouth.
Thyroid glands are not enlarged.
Integumentary
 Color- wheatish
 Hydration of skin- well hydrated
 Turgor- normal
 Edema- not present.
 Cyanosis - absent
 Pallor present- which represent moderate anemia.
Thorax and lungs
 With is inspiration and expiration chest rise in seen.
 Breath sounds are clear
 In chest(heart) S1 and S2 sounds are clearly heard.
 Capillary refill time is <2 sec.
 Chest deformity absent.
Breast:
On inspection
 Bilateral Breast are symmetrical in shape and size.
 Nipples are erected
 Secondary areola is present.
 Montgomery tubercles are clearly visible.
 No signs of redness and swelling seen.
On palpation
 No hard mass or nodules are felt.
 Breast engorgement is not seen.
 Colostrum can be squeezed out easily.
Abdomen
On inspection:
 Appropriate to gestational age.
 Spherical in shape.
 Linea nigra present
 Straie gravidarum is present.
On palpation
 Fundal grip- soft irregular nodular mass is palpable which represents fetus buttocks.
 Lateral grip- On right side hard resistance structure is felt which represents back of the fetus.
On left side numerous small irregular mobile parts are felt which represents fetal
limbs
 Pawlik grip- mobile mass is felt. Which represent that head is not engaged.
  Pelvic grip- it shows that head is not engaged
 So, it’s ROA position and cephalic presentation
On auscultation.
 FHR present 138/min.
Genitourinary tract
 Urine frequency is 6 times / day
 Color of urine is pale yellow.
 Vaginal discharge is present which is white mucous in characteristic.
Gastrointestinal system
 Pain in abdomen is present due to contraction. But no pain related to GI system seen or
observed.
 Dysphagia is absent.
 No complaints of constipation.
Musculoskeletal system
 Posture: posture of mother is normal
 Gait: waddling gait.
 Normal curvature of spine.
Neurologic assessment
 Mother is conscious.
 Mother is disoriented to place, time and person due to unconscious state.
INVESTIGATIONS
s.no. Investigation Normal value Patient value Remarks
1. Blood group B-ve Rh(-ve)
2. Hb 13-16gm/dl 12.5 gm/dl Normal
4. TLC 4500-11000/cumm 11900/cumm Normal
5. Platelet 150000- 167000/cumm normal
400000/cumm
6. Neutrophills 40-75% 73.1% Normal
7. lymphocytes 20-40% 16% Normal
8. Basophils 0-1% 0.1% Normal
9. esinophils 1-6% 4.6% Normal
10. Monocytes 2-6% 7.7 % Increased
11. RBC 4.5-5.5mil/cumm 3.87 mil/cumm Normal
12. MCV 83-99 95.9 Normal
13. MCH 27-32 31.4 Normal
14. HIV Non-reactive Non-reactive Normal
15. VDRL Non-reactive Non-reactive Normal
16. HBsAg Non-reactive Non-reactive Normal
17. Triple T test Low risk Low risk normal
 18. Kidney function Normal
test
Urea 13-43 mg/dl 11.0
creat 0.2-1.2 mg/dl 0.3
19. SGPT 1-31 U/L 23 Normal
20. SGOT 1-34 U/L 30 Normal
21. Total Bilirubin 0-1.2 mg/dl 8.7 Normal

ULTRASOUND.
Done on 16/8/19- shows single live intrauterine fetus cephalic presentation, fetal movements and
cardiac activity appreciated, with no loop of cord around neck, cephalic presentation, FHS- 142/mt.
Placenta- Right lateral anterior- posterior, grade I upper segment. Liquor is adequate.

DOCTOR’S ORDER
S Date Medication/treatment action
no.
1. 22/9/19 PC Enema To evacuate bowel
2. 22/9/19 Induction of labor with To augment labor.
cervical gel
3. 22/9/19 Inj oxytocin 2 unit in To induce labor
500 ml RL
4. 23/9/19 Tab pantocid 40mg BD Proton pump inhibitor
P/O
5. 23/9/19 Tab Becosule 1 tab OD Vitamin B suppplement
P/O
6. 23/9/19 Tab combiflam 500mg Non-steroidal anti inflammatory drug
TDS P/O
7. 23/9/19 Perineal care with To prevent infection
Betadine
8. 23/9/19 Tab moxidase 1 tab Antibiotic
TDS P/O
9. 23/9/19 Tab udiliv 300mg TDS Suppress hepatic synthesis and secretion of cholesterol
P/O and also inhibits intestinal absorption of cholesterol.

CASE IN DETAIL
RH INCOMPATIBILITY
Isoimmunisation (all immunization) is defined as a product of immune antibodies in an individual in
response to an antigen derived from another individual of the same species provided, the first one lacks
the antigens.
It occurs in two stages:
1) Sensitisation
2) Immunisation
This is in contrast to ABO groups, where there are naturally occurring isoimmune anti – A and anti –
B antibodies.

METHODS
1) Transfusion of mismatched blood
In ABO group incompatibility, there are naturally occurring anti- A and Anti B isoagglutinins, which
result in immediate adverse reaction. In case of Rh Group, there is no such naturally occurring antibody
and as such there is no immediate reaction but the red blood cells carrying the Rh antigens sensitise
the immunologically competent cells in the body, provided the amount is sufficiently large. This takes
at least one week. Following a subsequent exposure to the antigens, the cells are stimulated to produce
more specific anti- D antibody. The women may suffer a severe haemolytic reaction to the subsequent
mismatched transfusion.
2) As a result of pregnancy (Rh- negative woman bearing a Rh- positive fetus) . Normally, the fetal
red cells containing the Rh antigen, cannot mix with the maternal blood. But, in association with
certain complications or procedures as in abortion, CVS, amniocentesis, antepartum haemorrhage
or attempted version specially under anaesthesia. There is chance of feto-maternal bleed. This is
much more (15- 50%) likely to take place during third stage of labour and following Caesarean
section or manual removal of placenta. However, recent studies show a continuous feto-maternal
bleed occurring throughout normal pregnancies (1%).
Immunization is unlikely to occur unless at least 0.1ml of fetal enters the maternal circulation. Not all
“at risk” Rh-negative women become alloimmunised. About 17 percent of Rh-negative women will
become alloimmunised by a single Rh- incompatibility pregnancy. Rh- sensitisation due to antepartum
feto-maternal haemorrhage is about 1-2percent before delivery. Fetal Rh antigens are present by 38 th
day after conception. Spontaneous first trimester abortion carries 1-2 percent before risk and that of
induced abortion about 5 percent risk of sensitisation. Thus, affection of the baby due to Rh
incompatibility is low considering the increased number of Rh-positive babies delivered in Rh-
negative mothers.
The reasons are:
- Inborn inability to respond to the Rh antigen stimulus.
- Immunologic non-responder as found 30 percent of Rh negative mothers

INCIDENCE
The incidence of Rh negative individual varies by race with a low of less than 1% in Chinese and
Japanese to a high of 30-35% in Basques (spain), in whom the mutation likely originated. Caucasians
have an incidence of 15% and African Americans of 7-8%. In Indian and Asians this frequency of Rh-
negative population is around 5%.
About 40% of Rh-postive individuals are homozygous at the D locus (DD) while the remainder are
heterozygous (Dd).

GENOTYPE
The fetus receives its genetic components from both parents and thus the blood group of the fetus may
differ from the mother. The red cell membranes have various surface antigens like ABO, Rhesus amd
Kell groups and all of them are capable of starting an immune response in mothers.
The Rhesus blood group antigens compromise five antigens C,c,D,E and e. as D has not been identified
so d indicates absence of the D antigen. The CDE genes are located on the short arm of chromosome
1. The most immunogenic of these is the D antigen, its presence or absence denotes a person as Rh-
negative. In a Rh-negative mother and Rh-negative father, the probability of a Rh-positive fetus will
depend upon whether the father is heterozygous or homozygous (DD) seen kin 40% cases, whle a man
with D is only one set is called heterozygous (Dd) seen in 60% cases. If the father is homozygous, all
the offspring will be Rh-positive (Dd). If the father is heterozygous, half will be Rh negative.
PATHOGENESIS OF RH ISOIMMUNIZATION
Isoimmunisation is a process in which alloimmunizing antibodies are produced in a person against an
antigen from another person of the same species. When the mother is Rh-negative and the father Rh-
positive, the fetus can be Rh-positive and this can cause isoimmunisation, unlike ABO groups where
anti-A and anti-B are already present in serum, there are no naturally occurring antibodies against Rh
groups.
Hence, sensitization must take place for antibodies to be formed. Antibodies once formed remain
throughout life.
Antibodies associated with haemolytic diseases of newborn
1. Anti-D,c,E,e,C,K and Kell antibodies
2. Anti-D, anti-e and anti-K antibodies are most often associated with moderate to severe
haemolytic disease of newborn.
FACTOR DECIDING THE MATERNAL RESPONSE (why all Rh-negative women do not get
isoimmunised)
Although trans placental fetomaternal hemorrahage is fairly common, the occurrence of Rh-
isoimmunisation is rare. The degree of isoimmunisation depends upon following factors-
 Size of the inoculum (volume) of fetomaternal hemorrhage. As RhD antigen is very potent,
even a volume of 0.1 ml (the critical sensitizing volume) of RhD+ erythrocutes in Rhd-
individual stimulates the production of antibodies.
 Magnitude of mother’s immune response. About one-third women are non-responders
(variable antigenicity).
 Strength of the antigens stimulates also effects the response.
 Concurrent ABO incompatibility between mother and fetus. Risk of sensitization is affted by
the ABO blood group of the fetus with lesser risk if it is incompatible with mother’s ABO
group. When ABO incompatible fetal red cells enter the mother bloodstream, they quickly
combine with the naturally occurring anti-A and anti-B agglutinins and are neutralized and
cleared by them.
 Risk of sensitization is highest in first pregnancy and decreases with each subsequent
pregnancy.
 Du positive individual.
RISK OF ALLOIMMUNIZATION
 After Ist Rh-postive pregnancy
ABO compatibility (80%) = 16%
ABO incompatibility (20%) =1.5-2%
Postpartum Anti D only = 2%
Ante and postpartum Anti D = 0.1%
INCIDENCE OF ISOIMMUNIZATION’
A D-negative woman who has delivered a D-positive, ABO- compatible infant has a likelihood of
isoimmunisation of 16% (2% in ABO incompatible fetus and 2-5% after an abortion); 2% will be
immunized by the time of delivery, 7% will have anti-D antibody by ^ months postpartum, and the
remaining 7% will be sensibilized. In sensibilization, anti-D antibodies ate produced at avery low level
and are not detected during or after the current pregnancy but will be identified early in the next
pregnancy.
FACTORS PREDISPOSING TO FETO-MATERNAL HEMORRHAGE AND
SENSITIZATION
Sensitization can occur anytime during pregnancy but is more common in the third trimester and
during parturition. Although it can occur in the absence of sensitizing events, it is more common
in the presence of following conditions:
1) Miscarriage especially late miscarriage
2) Termination of pregnancy
3) Ectopic pregnancy
4) Partial molar pregnancy
5) Medical intervention
 Chorionic villus sampling
 Amniocentesis
 Cordocentesis
 External cephalic version
6) Maternal abdominal trauma
7) Antepartum hemorrahage
8) Manual removal of placenta
9) Caesarean delivery
10) Threatened preterm/preterm labor
11) Idiopathic
FETAL EFFECTS OF RH-ISOIMMUNIZATION (HEMOLYTIC DISEASE)
Fetal manifestation
The various fetal manifestations as per severity of the disease are as follows:
1) Immune hydrops (erythroblastosis fetalis)
Immune hydrops is the most severe variety of Rh isoimmunisation. In immune hydrops, excessive and
prolonged haemolyses of fetal red cells causes anaemia stimulating marked erythroid hyperplasia of
the bone marrow. There is increased extra medullary haematopoiesis in spleen and liver causing their
dysfunction. There may be cardiomegaly and pulmonary haemorrhages. Fluid collections in the fetal
thorax, abdominal cavity skin is the hallmarks of hydrops. Fetal hydrops occurs at a deficit of >7 g Hb
for that gestation.
The placenta is markedly enlarged, edematous, boggy with large, prominent cotyledons and edematous
villi. Hydrothorax may restrict lung development causing pulmonary compromise after birth. Ascites,
hepatomegaly and splenomegaly may lead to severe dystocia. Hydropic changes are easily diagnosed
on ultrasonography. The baby may be hydropic and stillborn with the signs of maceration.
Pathophysiology
Exact pathophysiology is unknown. Various theories are as follows.
 Heart failure from prolonged severe anaemia
 Capillary leakage caused by hypoxia with severe anaemia.
 Portal and umbilical venous hypertension from hepatic parenchymal disruption by
extramedullary haematopoiesis.
 Lower colloid osmotic pressure due to liver dysfunctional and hypoproteinemia.
Diagnosis
i. Blood group of women is Rh-negative.
ii. Positive maternal indirect Coomb’s test.
iii. There is usually associated hydraminos.
iv. There is usually a history of previous perinatal loss related to haemolytic disease of the
newborn in previous pregnancy.
v. Ultrasound findings: there may be fetal hydrops, fetal ascites, scalp and skin edema
pericardial or pleural effusion and hepatosplenomegaly in the fetus.
vi. There may be sinusoidal pattern on cardiotocography in severe affection due to fetal anemia.
vii. Maternal X-ray abdomen is not usually needed in modern obstetrics. If done in smaller centres.
It shows fetus in so called ‘Buddha Position’ with a halo around its head due to scalp edema.’
viii. Examination of the baby at birth. The baby may be hydropic and stillborn. If alive the baby
has pallor (anemia), grossly swollen body with enlarged abdomen due to ascites and associated
hepatosplenomegaly.
ix. Examination of placenta after delivery. Depending upon the severity of the disease, there
may be gross placentography with hydropic changes with liquid emantng from it. on
histopathological examination, there is persistence of cytotrophoblastic layer with marked
thickening of the chorionic villi.

As mother is having her first pregnancy so alloisoimmunisation is does not occurs

Diagnostic test- mother blood test was done and found Rh negative blood group.

2. ICTERUS GRAVIS NEONATRUM

It is a type Rh isoimmunisation in which baby is less severly affected as compared with immune
hydrops. Baby is usually born in good condition but jaundice appears within 24 hours of birth.
During in utero stage, excess of bilirubin from fetal red cell hemolysis which was being cleared
by the placental stops after birth leading onto neonatal anemia and jaundice form continued fetal
 red cell hemolysis. There is risk of kernicter in which excess levels of unconjugated bilirubin
may cross the blood brain barrier and may cross the blood brain barrier and may damage the
central nervous system especially, the basal ganglia and eighth cranial nerve nucleus causing
sensorineural deafness. It may occur if serum bilirubin levels in the baby exceed 20mg/dl and is
more likely to happen in premature dehydrated and sick babies. It is prevented and treated by
phototherapy, adequate hydration and exchange transfusion.
3. CONGENITAL HEMOLYTIC ANEMIA
it is least severe form of Rh isoimmunisation and is also called congenital anemia of the newborn.
As there is very mild hemolysis of the fetal red cells occurring in the baby, there is development
of mild to moderate anemia (pallor) in the baby very slowly with haemoglobin usually between
9-10g/Dl. Jaundice is usually absent. Initially due to extramedullary erythropoiesis, there may be
mild to moderate hepatosplenomegaly. The condition usually settles down by 6 weeks of life by
which time antibodies causing hemolysis are usually exhausted. Such infants usually need iron
supplementation but may rarely need blood transfusion or erythropoietin therapy if anemia
becomes severe.

CASE PICTURE- No congenital abnormality in newborn present.

MATERNAL EFFECTS
The maternal effects of congenital anemia of the newborn are less marked than fetal effects.
1. Higher chances of pre-eclampsia, hydraminos and macrosomic fetus. There is risk of
coagulopathy and hypofrinogenemia due to the dead fetus.
2. Increased incidence of postpartum hemorrhage due to placentography due to the dead fetus.
3. Mirror syndrome, it is caused by vascular changes in the placenta causing pre-eclampsia. The
mother develops edema similar to the fetus, hence the name.
4. Grandmother theory- rarely the D-negative female fetus is exposed to D antigen from the
mother and sensitized as a result. If such a sensitized female child grows up to bear an Rh-
positive fetus, the fetus is affected any antibodies initially provoked by its grandmother’s blood.
As this is very rare, anti D prophylaxis is not recommended.
5. Amnestic response- presence of an antibody titre in the mother need not necessarily depict the
fetal affection. Previously sensitized women may have a higher load during subsequent
pregnancies even if the current fetus is D-negative.
PREVENTION OF RH-ISOIMMUNIZATION
Injection Anti-D immunoglobulin (IgG) should be given to all Rh-negative mothers who have given
birth to Rh-Positive fetus.

CASE PICTURE- Mother received Anti D immunoglobulin

received

Mechanism of action
Exact mechanism is not known. Probable mechanism are as follows:-
1. Rapid macrophage mediated clearance of anti-d coated red blood cells.
 2. Down regulation of antigen-specific B cells before occurrence of immune response.
3. In the past it was believed that anti D blocked the Rh-antigen of the fetal red cells but a
significant number of RhD antigen sites on fetal RBCs in maternal circulation are not bound by
passive anti D. Hence, epitome masking is not of fractionation, ultrafiltration and screening
techniques.
Anti D immunoglobulin is extracted by cold alcohol fractionation from plasma donated by
alloimmunized women and male donors (given repeated injection of RhD+ red cells to develop high
titred polyclonal anti D plasma. It is free of viruses and other infection due to use of fractionation,
ultrafiltration and screening techniques.
Current Recommendation for Immunoprophylaxis
1. After delivery within 72 hours postnatal prophylaxis with 300 μg anti d immunoglobulin
intramuscularly (preferably in deltoid muscle) is given to all Rh-negative women with Rh-positive
baby and negative cord blood direct Coomb’s test (grade 1 A recommendation). If anti d is
inadvertently omitted after delivery, some protection has been proven with its administration up to
13 days. Recommendation is that it should be administered up to 28 days after delivery if omitted
by mistake. Screening test should be done to identify women with large fetomaternal hemorrhage
needing additional anti D injection.
2. Anti D should be given after sensitizing events before delivery and after abortion in dose of 50 –
100 μg before 20 weeks and 300 μg after 20 weeks.
3. In spontaneous abortion before 12 weeks without surgical intervention, anti D is not necessary.
However, if any surgical intervention has been carried out, it is indicated.
4. Two doses of 100 μg anti D are recommended and given at 28 weeks and 34 weeks of gestation in
United Kingdom and Canada (Grade 1A recommendation) American College of Obstetricians ans
Gynecologists (ACOG, 1999) recommends single dose of 300 μg of anti D at 28 weeks of gestation
followed in India. This practice reduces the incidence of isoimmunisation from 2% with only post
delivery anti D to 0.1%. as half-life of anti D is only 24 days and protective effect of anti D lasts
for about 6 weeks, post-delivery anti D is still required despite antepartum prophylaxis.
5. Women who are weakly RhD+ (previously Du positive) are not at risk of RhD alloimmunisation
and do not require anti D prophylaxis.
6. When in doubt it is better to give anti-D as it causes no harm but not giving it an indicated case
may have serious consequences. Women undergoing ligation should also be given anti D as they
later come back recanalization.
The indication of prophylaxis is:
Indication of Anti-D immmunoprophylaxis
Early pregnancy Late pregnancy
1. Threatened abortion 1. Late miscarriage
2. Miscarriage 2. Amniocentesis
3. Medical or surgical MTP 3. Cordocentesis
4. Ectopic pregnancy (medical or surgically 4. Fetal surgery or intervention
managed) 5. Antepartum hemorrhage
5. Hydatidiform mole especially partial 6. External cephalic version
(trophoblast cells may express D-antigen) 7. Routine cephalic version
6. Chorionic villus sampling 8. Routine antepartum prophylaxis (28
7. Other intrauterine procedures weeks)
 8. Multifetal reduction 9. Manual removal of placenta.
MANAGEMENT OF IMMUNIZED PATIENT
Amniocentesis and amniotic fluid bilirubin evaluation
The amount of bilirubin correlates with the degree of severity. Likely 1961 establishment
spectrophotometry as a method to assess amniotic fluid bilirubin concentration as in amniotic fluid.
Indications
 The antibody titre is more than 1:16 (critical titre) to determine whether the baby will be
affected or not.
 Previous history of severely isoimmunised or not.
 Father is heterozygous to determine whether this baby will be affected or not.
Timing of amniocentesis
Amniocentesis is performed at 30-32 weeks or 10 weeks before the gestation of last stillbirth and
should be repeated after 3-4 weeks.
Interpretation
Using spectrophotometr, the optical density ‘deviation bulge’ of liquor is observed at 450 nm
wavelength for the severity of fetal hemolysis. The height of the deviation bulge falls within one of
the three zones when plotted in Liley’s graph depending upon the gestation.
FETAL BLOOD SAMPLING AND INTRAVASCULAR TRANSFUSION
Fetal blood sampling and intravascular transfusion is the best method to assess and treat fetal anemia
and should be done in a regional guidance. It is indicated in selected cases where there is severe
affection of the fetus in-utero prior to 34 weeks or fetal haematocrit < 30% or single value in zone #
of Liley’s graph to correct fetal anemia and improve oxygenation.

INTRAVASCULAR TRANSFUSION
Intravascular transfusion is favoured as it has proven efficacy and safety and is better than peritoneal
transfusion.
Procedure
Transfusion is generally made through umbilical cord vessels (vein) near its insertion into the placenta
under ultrasonographic guidance. Blood group ‘O’ Rh-negative packed cells (hematocrit 90%) or
compatible with mother’s blood are transfused to achieve a fetal haematocrit of 50%.
Usually 40 to 60 ml blood is given in one sitting. Haematocrit falls by 1% per day. Intrauterine
transfusion is repeated once haematocrit falls below 30% (7 to 14 days). It can be strated at 18 weeks
and can be repeated every 1-2 weeks until 34 weeks.
Caesarean section is advisable considering severity of fetal affection and need of urgent delivery.
TERMINATION OF PREGNANCY
The patient should be shifted to an equipped centre with an intensive neonatal care unit with facilities
for exchange transfusion and an expert neonatologist to manage affected babies.
Termination of pregnancy is done in immunized mothers with evidences or fetal hemolysis inutero
after considering the following factors:
i. Previous history of stillbirth with father being homozygous
ii. Sudden rise in maternal antibody titre
iii. Increased middle cerebral artery peaks systolic velocity
iv. The optical density difference falling in upper zone 2 or zone 3 on Liley’s graphy
v. Ultrasonographic features of fetal affection
TIMING OF DELIVERY
In middle affection, the pregnancy may be continued up to 38 weeks and then termination is to be
done.
In severe affection, it is better to terminate the pregnancy at 34 weeks after giving steroids at 32 weeks
for fetal maturity.

CASE PICTURE- Mother is delivered after 38 weeks.

METHODS OF TERMINATION
Vaginal Delivery
Amniotomy (low rupture of the membranes) is quite effective, if termination is done near term, as
most of the cases are parous women. Vaginal prostaglandin gel (PGE2) can be used to make the cervix
ripe. Oxytocin drip may be continued, if needed.
Caesarean Section
If termination has to be done for severe affection prematurely (say 34-37 weeks), with unfavourable
cervix, caesarean delivery is preferred.
Other therapies like plasmapheresis, administration of promethazine and immunosuppression with
corticosteroids are not used any more. Intravenous immunoglobulin (IVIG) therapy in high dose (1000
mg/kg body weight) can be used.
CLAMPING UMBILICAL CORD
The umbilical cord promptly clamped to minimize feto-maternal blood mixing to the mother. The cord
is kept as long as possible (about 15 cm) as baby may need exchange transfusion.
COLLECTION OF CORD BLOOD IN ALL RH-NEGATIVE PATIENTS
Cord blood 5 ml is taken from the placental end of the cord.
1. Oxalated/EDTA Blood. 2 ml for hemoglogulin estimation, haematocrit and peripheral smear for
hemolysis.
2. Clotted blood. 3 ml for blood group, direct Coomb’s test and serum bilirubin.
EXCHANGE BLOOD TRANSFUSION IN NEWBORN
Newborn exchange transfusion is a very useful and life-saving procedure which removes hemolyzed
and antibody coated red blood cells and unattached antibodies and replaces them with donor red blood
cells which lack sensitizing antigen in affected foetuses. It helps baby in critical first two weeks after
which the infant’s own blood forming mechanism usually takes over. Ultimately the baby’s blood
group will not change and will remain Rh-positive due to inherent tendency of making Rh-positive
cells.
INDICATIONS
1. Cord haemoglobin value of 10gm/dl or less (or haematocrit of <30%)
2. Cord bilirubin concentration of 5 mg/dl or more
3. Increase in newborn’s bilirubin at rate of >1mg/dl/hour
4. Term infants with bilirubin levels > 20 mg/dl
5. History of kernicterus or severe erythroblastosis in previous baby in past.
6. Reticulocyte count of > 15% and prematurity are additional indications of exchange
transfusion.
7. Repeat transfusion is indicated if Hb falls < 10 g/dl or bilirubin rises to 20 mg/dl or more.
TECHNIQUE
Blood for transfusion should be as fresh as possible. Heparin or citrate phosphate dextrose adenine
solution is used for anticoagulation. Before delivery, blood should be kept ready from a type), Rh-
negative donor with low titre of anti A and anti B antibodies and should be tested for compatibility
with the mother’s serum using indirect Coomb’s test. After delivery, blood should be taken form
coomb’s test. After delivery, blood should be taken from either type O, Rh – negative donor (preferred
from Rh- negative donor with the same ABO group as baby when mother also has same group after
testing for compatibility (cross matching) with the sera of both mother and the baby. Blood should be
gradually warmed to a temperature between 35-37oC and should be kept well mixed by gentle
squeezing to avoid sedimentation. Stomach of baby should be emptied by gastric tube to prevent
aspiration, body temperature should be kept constant and warm and vital signs should be monitored.
An experienced paediatrician (neonatologist) accompanied by a competent assistant should be perform
the procedure and monitor the baby. The proceed should be performed only in experienced neonatal
referral centers.

Under all strict aseptic conditions, the umbilical vein is cannulated with a polyvinyl catheter (about 1
mm diameter) to a distance of about 7 cm in a full term baby when full free flow of blood is achieved
indicating the position of catheter to be in a large hepatic vein or the inferior vena cava. As an
alternative exchange may be carried out through peripheral veins (for infusion) and arteries (to draw
out blood). The exchange is carried out over 45-60 minutes using 35-40 cycles of aspiration of an
aliquot of 3-5 Ml /KG (less for preterm and sick infant) followed by transfusion of same aliquot (3-5
ml/kg) of donor blood (pull-push method) with one cycle taking 60-90 seconds. The goal is to
exchange about two blood volumes of the baby (about 170ml/kg body weight). Haematocrit and
bilirubin levels are measured before and after the transfusion. Bilirubin levels are measured every 4-8
hours. Intensive phototherapy is started to keep bilirubin under control. Repeat transfusion is
performed if serum bilirubin rises to 20mg/dl or more inspite of phototherapy.
Sodium bicarbonate and calcium gluconate are not routinely used but given if acidosis or tetany
develop. Baby is continuously monitored during and after transfusion for vital signs, any bleeding or
infection at umbilicus site, and estimation of haematocrit, bilirubin and glucose levels. Antibiotics
should be given for three days.

COMPLICATIONS
Exchange transfusion is not without complications and should only be done in tertiary referral centres
with adequate technical skills and good bank facilities. The complications are as follows:
Acute complications
They are observed in 5 – 10% cases.
1. Risk of death: 0.3/100 procedures in experienced hands. Death can occur due to apnea,
bradycardia or heart failure or other complication.
2. Transient bradycardia
3. Cyanosis
4. Transient vasospasm
5. Apnea
6. Thromboembolism
7. Congestive heart failure
8. Acidosis due to citrated blood
9. Hypoglycemia
10. Thrombocytopenia
11. Tetany
12. Infection

Late complications
1. Late anemia which may be haemolytic or hyporgenerative bone marrow.
2. Graft versus host reaction manifesting as rash, diarrhoea, hepatitis or eosinophilia.
3. Necrotizing enterocolitis is a rare complications.
4. Risk of infection of CMC, HIV and hepatitis form blood transfusion.
5. Inspissated bile syndrome
6. Portal vein thrombosis and portal hypertension possibly due to prolonged trauma or septic
umbilical vein catherization
7. Kernicterus

ADJUVANT THERAPY
1. Phototherapy
Use of phototherapy decreases the need for exchange transfusion especially need for repeated
exchange transfusion by causing photo oxidation (degradation) of bilirubin. Narrow spectrum blue
light (450-460 nm) are most effective but broad spectrum while and blue light (420-470 nm) are
also effective. Bilirubin which can be excreted in bile without conjugation. Other major structural
isomer formed from bilirubin after photoisomerization to 4Z, 15E bilirubin which can be excreted
in bile without conjugation. Other major structural isomer formed from bilirubin after
photochemical reaction is lamirubin which can be excreted by kidneys. Baby’s eyes should be
protected by covering or using dark glasses to avoid damage especially to the retina. Hydration,
fluid requirements are increased and IV fluids should be given.

Intravenous immunoglobulin:
Its use is advocated when serum bilirubin rises to dangerous levels despite phototherapy. Given in
dose of 0.5 – 1.0g/kg/dose 12 hours apart reduces the need of exchange transfusion possibly by
decreasing haemolysis. However, recent studies do not recommend its uses.

Erythropoietin
Use of subcutaneous erythropoietin 400 U/ Kg thrice a week for 2 weeks decreases need of repeated
transfusion. Supplementation iron 6mg/kg/day is also given.

2. Phenobarbitone is given thrice daily intramuscularly in dose of 3-5mg/kg body weight to clear
bilirubin by stimulating conjugation.
3. Antibodies are given for 3-5 days to prevent sepsis.
PROGRESS NOTES
DAY 1
Day 1 – 23 september 2019
Patient was in labor having moderate contractions.
Full term normal delivery with right medio lateral episiotomy.
Onset of true labor pain occurs at 12:10 am. At 9:00 am cervix was fully dilated. Mother is shifted to
delivery room. Inj xylocaine 2% 10 ml infiltrated in per perineum. RMLE given at the peak of
contraction and at crowning. Delivered baby boy at 23/9/19 at 9:20 am as vertex presentation. Baby
cried immediately after birth. Cord clamped and cut. Inj synto 10 unit I/M stat given placenta expelled
with complete membrane at 9:30 am. Episiotomy sutured in layers. Uterus well contracted. No PPH
seen. Placenta expelled weight 448 gm and cord length 47cm.

Baby cried immediately after birth with vertex presentation on 23/9/19 at 9:20am. Baby cried
immediately after birth. Cord clamped and cut. Baby is kept in radiant warmer. Oropharyngeal and
nasopharyngeal suction done. Eye care given. ID band applied. APGAR score at 1 min – 8/10 and at
5 min – 10/10
Inj Vitamin K 1 mg 1/M stat given.
Inj hep B 0.5 ml I/M stat given.

Mother is then kept in post natal room and then shifted to postnatal ward.
General condition is fair
 Patient is afebrile
 Oedema absent
 Pallor present
 Pulse: 88/mt
 BP: 110/80mm/hg
 Chest/CVS- NAD
 Initial assessment was done.

DAY 2
Date – 24/9/2019

General condition of the mother is fair. Post natal day 1. Mother is conscious and oriented.
 Vital signs checked and assessed.
Temp- 36.4OC
Pulse- 84/mt
Resp- 22/mt
BP-118/76 mmHg
 Fundal height checked. PNC day 1- 14.5 cm
 Post natal assessment done.
 Breast are soft and secretory.
  Episiotomy is clean and healthy. No sign of infection seen
 Lochia rubra is within normal limits.
 Perineal care given.
 Urine passed.
 Stool passed
 No fresh complaints.
 Health education given regarding proper technique of breast feeding.

 New born assessment done. No congenital abnormality present .

Temp:37.2OC
Resp- 44/mt
Heart Rate-142/mt
Weight of baby- 2.56 kg
Head circumference- 34.5cm
Chest circumference- 31.5 cm
Abdominal girth- 28.7cm
Baby is active and healthy

DAY 3
Date – 25/9/2019

General condition of the mother is fair. Post natal day 1. Mother is conscious and oriented.
 Vital signs checked and assessed.
Temp- 37.2OC
Pulse- 88/mt
Resp- 20/mt
BP-110/74 mmHg
 Fundal height checked. PNC day 1- 13.5 cm
 Post natal assessment done.
 Breast are soft and secretory.
 Episiotomy is clean and healthy. No sign of infection seen
 Lochia rubra is within normal limits.
 Perineal care given.
 Urine passed.
 No fresh complaints.
 Health education given regarding proper technique of new born care

 New born assessment done. No congenital abnormality present .

Temp:36.9OC
 Resp- 46/mt
Heart Rate-144/mt
Weight of baby- 2.55 kg
Abdominal girth- 28.6cm
Baby is active and healthy

DAY 4
Date – 26/9/2019
General condition of the mother is fair. Post natal day 1. Mother is conscious and oriented.
 Vital signs checked and assessed.
Temp- 36.2OC
Pulse- 80/mt
Resp- 20/mt
BP-110/78 mmHg
 Fundal height checked. PNC day 1- 12.5 cm
 Post natal assessment done.
 Breast are soft and secretory.
 Episiotomy is clean and healthy. No sign of infection seen
 Lochia rubra is within normal limits.
 Perineal care given.
 Urine passed.
 No fresh complaints.
 Health education given regarding proper technique of family planning methods
 New born assessment done. No congenital abnormality present .
Temp:36.3OC
Resp- 44/mt
Heart Rate-142/mt
Weight of baby- 2.53 kg
Abdominal girth- 28.4cm
Baby is active and healthy
HEALTH EDUCATION:

1. Rest and Sleep: Ensure adequate rest and sleep for mother. She should not be disturbed for trivial
reasons. She should be protected from undue anxiety and friends. If mother experiences inadequate
sleep due to after pains, breast engorgement, anxiety or tiredness while caring for the baby, she
should be given appropriate medications. Mother should rest for 2 hours a day in horizontal position
to aid in optimum healing of pelvic floor muscles. Visitors should be restricted.

2. Early Ambulation: Encourage mother to be out of bed within the first 48 hours of the delivery of
a baby or according to her comfort level. Explain the mother that it will prevent many complications
such as bladder complications, constipation and she will feel better after ambulation.

3. Hygiene: Mother should be given perineal care with anti-septic lotion every 4-6 hours. If she has
episiotomy or indwelling catheter, when she is capable of self-care, advise her to maintain her ham
and perineal hygiene. Breasts should be cleaned while taking bath and before and after feeding.
Vulva pads should be changed frequently. Perineal wash-down should be done twice daily. Hand
washing should also be practised before and after handling the baby.

4. Care of Bladder and Bowel: Mother should pass urine within 6-8 hours of delivery. Encourage
her to void frequently in order to avoid bladder distension. If constipation persists, mother may be
given laxatives. Diet should contain sufficient roughage and fluids.

5. Diet: If mother has had normal vaginal delivery, she can be given something to eat and drink 2
hours after delivery. The diet should contain plenty of proteins, meat, fish, fresh fruits and green
vegetables. The total diet should have additional 400-700 K/cal to meet lactation need. Iron
supplementation should be continued for at least 3 months after delivery.

.6. Rooming in: The baby should be kept on mother’s bed to allow her cuddling, fondling, kissing
and gazing at the baby. It helps to build mother-child relationship and mother can observe her baby
as well.

7. Postnatal Exercises: Mother should rest for 24 hours after delivery. After that, she can gradually
start exercises. Exercises are helpful in firming the figure and toning the musculature.

8. Contraception: Need for contraception should be discussed Within the hrst week of delivery.
Mother should be explained about the various methods of contraception available among which she
can choose according to her own need.

9. Education: Mother should be educated about self-care and baby-care. She should be informed
about baby-Clothing, baby-bathing, breastfeeding, care of buttocks and umbilicus, weight gain of the
baby, immunization and physiological jaundice. Advise her about regular follow-up as suggested by
the physician in postnatal OPD.

10. Immunization of Mothers: Administration of anti D-gamma globulin to un-immunized Rh-

negative mother bearing Rh-positive baby and woman who is not immunized against rubella should
be given rubella vaccine in the post-partum period.

11. Emotional Needs: Mothers need support as they adjust to this experience of being mothers.
Encourage them and show confidence in mothers’ ability. Don’t compare another {With other
mothers. She may suffer from post-partum blues, so provide her the reassurance. Observe for the
symptoms of depression and need for counselling.

12. Breastfeeding and Care of Breast: Wear a well-fitting bra. Keep breast and nipples clean by
washing with water before and after feeding the baby. Allow demand feeding and exclusive
breastfeeding for the first 6 months.

SUMMARY AND CONCLUSION

Mrs. Subra Zehra w/o Mr Mohd Yaseen primigradiva with 38+5 weeks of POG with rh negative
pregnancy admitted on 22/3/19 with complaints of labor pains. She delivered a male baby on 23/9/19
at 9:20am. Baby cried immediately after birth. Baby is active and healthy. Detailed history collection
was done. Nursing care of four days Postnatal care was given. During this time, I provide holistic
nursing care.
This case study helps me to know about the disease condition and compare the information from the
patient to book picture.
BIBLIOGRAPHY

• Sharma JB, Textbook of Obstetrics, Avichal publishing Company, 2nd edition, page no. 385-
397
• Mudaliar A.L., Menon M.K. Krishna, Clinical Obstetrics, orient longman publication, 8th
edition page no.
• Whilson Robert, Beecham Clayton M., Carrington Elise Ried, Obstetrics and Gynecology, The
C.V. Mobsy Company, 5th edition page no. 124-129
• Bookmiler Mae M, Bowen George L., Textbook of obstetrics and Obstetric Nursing, W.B.
Saunders Company publication, 4th edition page no. 267-284
• Dutta D.C., Textbook of obstetrics, New Central Book agency publication 6th edition page no:
235-249