Misamis University Graduate School

Master in Nursing/Master of Arts in Nursing

213-INTENSIVE PRACTICUM 2
Second Semester, S.Y. 2022-2023

A CASE STUDY OF FETAL MACROSOMIA

(Normal Spontaneous Vaginal Delivery)

STUDENT:
PROFESSOR:

PATIENT’S DEMOGRAPHIC DATA

 PATIENTS INITIAL:
 AGE:
 ADDRESS:

 OCCUPATION:
 DATE OF ADMISSION:

BRIEF HISTORY OF PRESENT ILLNESS/ OB HISTORY

CHIEF COMPLAINT’S 3hours PTA of labor pain.

MEDICAL DIAGNOSIS
 ADMITTING DIAGNOSIS -PU 39 6/7 weeks Aog, G3P2
-G3P3 (3003) Pregnancy uterine delivered by normal
 FINAL DIAGNOSIS vagina delivery, cephalic term baby boy, fetal
macrosomia, large in gestational age, Apgar score 8-9,
bw:4400gms.

OBSTETRIC HISTORY Gravida-3, Parity-3, Living-3

LMP: 7/18/2022 EDD:4/25/2023
Pregnancy uterine 39 6/7 weeks aog

PHYSICAL EXAMINATION GENERAL SURVEY: Alert, Awake

VITAL SIGNS: BP:130/80mmHg; HR:107bpm;
RR:21cpm; Temperature: 36.2 °C
ABDOMEN: Gravid FH42 cm, FHT: 148bpm RLQ
Cephalic
 GU/IE:IE 10 cm (+) intact bow
CHEST AND LUNGS: Clear breath sounds

LABORATORY:
HEMATOLOGY
WBC 10.14
RBC 4.49
HEMOGLOBIN 11.6
HEMATOCRIT 33.7
PLATELET 469

URINALYSIS
PROTEIN TRACE
PUS CELLS 18-20 BLOOD CHEMISTRY
HBA1C 7
RBC 1-3
CREATININ 34.0
EPITHELIAL CELLS FEW
E
FEW SGOT 34.7
MUCUS THREADS
SGPT 50.6
BACTERIA MANY

Fetal Macrosomia

Fetal macrosomia is a condition in which the fetus is larger than average (between 4,000 grams
[8 pounds, 13 ounces] and 4,500 grams [9 pounds, 15 ounces]. Delivering a large baby can be
difficult, with more risk for vaginal tears or problems pushing your baby out. There are many
causes, including diabetes or obesity in the birth parent. While fetal macrosomia is unpredictable,
promoting good health and a healthy pregnancy can help prevent it.

WHAT ARE THE SIGNS OF FETAL MACROSOMIA?

 Have a large fundal height (a measurement of fetal growth).

 Have gained a lot of weight during pregnancy.
 Have diabetes, or were diagnosed with gestational diabetes.
 You’ve previously delivered a large baby.
 You’ve gone past your due date.
 You were a big baby yourself.
Complications

Fetal macrosomia poses health risks for you and your baby — both during pregnancy and
after childbirth.

 Maternal risks include:

o Labor problems- Fetal macrosomia can cause a baby to become wedged in the
birth canal (shoulder dystocia), sustain birth injuries, or require the use of forceps
or a vacuum device during delivery (operative vaginal delivery). Sometimes a C-
section is needed.
o Genital tract lacerations- During childbirth, fetal macrosomia can cause a baby
to injure the birth canal — such as by tearing vaginal tissues and the muscles
between the vagina and the anus (perineal muscles).
o Bleeding after delivery-Fetal macrosomia increases the risk that your uterine
muscles won't properly contract after you give birth (uterine atony). This can lead
to potentially serious bleeding after delivery.
o Uterine rupture- If you've had a prior C-section or major uterine surgery, fetal
macrosomia increases the risk of uterine rupture during labor — a rare but serious
complication in which the uterus tears open along the scar line from the C-section
or other uterine surgery. An emergency C-section is needed to prevent life-
threatening complications.

 Newborn and childhood risks include:

o Lower than normal blood sugar level- A baby diagnosed with fetal macrosomia
is more likely to be born with a blood sugar level that's lower than normal.
o Childhood obesity-Research suggests that the risk of childhood obesity increases
as birth weight increases.
o Metabolic syndrome-If your baby is diagnosed with fetal macrosomia, he or she
is at risk of developing metabolic syndrome during childhood.

ETIOLOGY
REFERENCE PATIENT
 Having a family history of fetal  Heavy Eating
macrosomia  Diabetic
 Excessive weight gain during pregnancy
 Obesity during pregnancy
 Multiple pregnancies
 A pregnancy lasting more than 40 weeks
 A mother with an above-average height
and weight
  Having a male child

Prevention

You might not be able to prevent fetal macrosomia, but you can promote a healthy pregnancy.
Research shows that exercising during pregnancy and eating a low-glycemic diet can reduce the
risk of macrosomia.

For example:
 Schedule a preconception appointment
 Monitor your weight
 Manage diabetes
 Be active

PATHOPHYSIOLOGY
 MANAGEMENT:
It isn’t necessary to get a C-section if your baby is expected to have fetal macrosomia. Your doctor
will monitor your labor carefully for any complications that might arise.
NURSING RESPONSIBILITIES
MATERNAL STATUS
 Monitor blood pressure.
 Monitored frequency for uterine contraction.
 Checked for any signs of vaginal tear and repair.
 Administer prescribed medications per physician’s order.
 Checked for any signs of vaginal bleeding.
 Monitored blood glucose level.
 Monitored for any signs for hypoglycemia.

NEWBORN STATUS
 Monitored blood sugar level.
 Monitored for any fracture.
 Maintained pediatric check-up for any signs of metabolic malfunctions.

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Subjective: Risk for After 8 hours of nurse -Teached the importance of
“Dako lagi altered and patient interaction, regularity of meals and After 8 hours
akoang baby sa nutrition: less the patient will be able snacks. series of nursing
ultrasound” as than body to verbalized her interventions,
verbalized by the requirements understanding about -Teached the client to goals are met,
patient. gestational diabetes. monitor sugar level and patient was able to
knows its importance. demonstrate an
Objective: improved
-Gravid fundic -Educated patient about behaviours and
height at 42cm proper diet. lifestyle.

-Informed patient about the

re-occurrence of large baby
in its gestational age for
future pregnancy.
DRUGS STUDY:
GENERIC NAME OXYTOCIN
CLASSIFICATION UTEROTONIC
DOSSAGE 10 “IU/ML”
ROUTE IVTT, IM, IV infusion
FREQUENCY 10 “U” IM single dose after delivery

MECHANISM OF ACTION Synthetic oxytocin elicits the same pharmacological

response produced by endogenous oxytocin, with cervical
dilation, parity, and gestational age as predictors of the
dose response to oxytocin administration for labor
stimulation. Oxytocin increases the sodium permeability
of uterine myofibrils, indirectly stimulating contraction of
the uterine smooth muscle. The uterus responds to
oxytocin more readily in the presence of high estrogen
concentrations and with the increased duration of
pregnancy.

INDICATIONS To induce parturition in cases of uterine inertia during 3 rd

stage of labor. As therapy and prophylaxis in cases of
placental hemorrhage and uterine atony.

CONTRAINDICATIONS Hypertonic uterine contractions, fetal distress when

delivery is not eminent. Placenta previa, abruptio
placentae. History of major uterine surgery.

SIDE EFFECT CNS: Headache, Nausea, Dizziness

CV: Cardiac arrhythmias, Hypotension

SKIN: Rash

1.) Discontinue oxytocin infusion immediately in the

NURSING event of uterine hyperactivity or fetal distress.
RESPONSIBILITIES
2.) Monitor fetal heart rate, resting uterine tone and
frequency, duration and force of contractions.

3.) Maintained and accurate rate of infusion flow.

GENERIC NAME METHYLERGOMETRINE MALEATE
CLASSIFICATION ERGOT ALKALOIDS
DOSSAGE  AMPULE: 200mcg/ml
 Tablet: 125mcg
ROUTE IM and ORAL
 1amp IM single dose after birth
FREQUENCY  1 tab 3 times a day for 4 days

MECHANISM OF ACTION Methylergometrine acts directly on the smooth muscle of

the uterus and increases the tone, rate, and amplitude of
rhythmic contractions through binding and the resultant
antagonism of the dopamine D1 receptor. Thus, it induces
a rapid and sustained tetanic uterotonic effect which
shortens the third stage of labor and reduces blood loss.

INDICATIONS Management of third stage of labor in normal

confinement. Management for post-partum hemorrhage.
Promotion of uterine involution.

CONTRAINDICATIONS Severe persistent sepsis. Vascular disease. Impaired

hepatic renal function. First stage of labor.

SIDE EFFECT GI: Abdominal pain

CV: Hypertension, Bradycardia , Tachycardia,
Palpitations, Chest pain
CNS: Headache, Nausea vomiting, Convulsions,
SKIN: Skin eruptions

NURSING  Monitored patient for any signs of increased blood

RESPONSIBILITIES pressure (severe headache, blurred vision,
pounding in your neck or ears);
 Informed mothers not breast-feed during treatment
with Methergine and at least 12 hours after
administration of the last dose. Milk secreted
during this period should be discarded.
 Monitored patient for any signs of burning,
crawling, itching, numbness, prickling, "pins and
needles", or tingling feelings.
GENERIC NAME CO- AMOXICLAV
CLASSIFICATION ANTIBIOTIC
DOSSAGE 625mg
ROUTE ORAL
FREQUENCY 3 times per day

MECHANISM OF ACTION
It works by stopping the growth of bacteria. Clavulanic
acid is in a class of medications called beta-lactamase
inhibitors. It works by preventing bacteria from
destroying amoxicillin.

INDICATIONS Shorterm treatment of possible infections of skin and soft

tissue. Also a bactericidal over a wide range of organisms.

CONTRAINDICATIONS Possible cross sensitivity with other beta-lactam

antibiotics. History of penicillin- assoc jaundice/hepatic
dysfunction.

SIDE EFFECT GI: GI disturbances

SKIN: Rash

NURSING 1.) Assess patient for any signs and symptoms of

RESPONSIBILITIES drug reaction throughout the therapy.

2.) Obtain a history, before initiating therapy, to

determine previous use of and reactions to other
antibiotic. Persons with a negative sensitivity may
still have an allergic response.

3.) Observe patient for signs and symptoms of

anaphylaxis (rash, pruritus, laryngeal edema,
wheezing). Discontinue the drug and notify
physician.

4.) Instruct patient to report signs of hypersensitivity.

GENERIC NAME MEFENAMIC ACID
CLASSIFICATION ANTI-PYRETIC

DOSSAGE 500mg
ROUTE ORAL
FREQUENCY 3 times per day

MECHANISM OF ACTION Anti- inflammatory analgesic activity, inhibits

prostaglandins and leukotriene synthesis.

INDICATIONS Short term management of pain (up to 5 days)

CONTRAINDICATIONS Mefenamic acid is contraindicated in patients

with salicylate hypersensitivity or NSAID hypersensitivity
who have experienced asthma, urticaria, or other allergic
reactions after taking aspirin or other NSAIDs. Severe,
rarely fatal, anaphylactoid reactions to mefenamic acid
have been reported in such patients.

SIDE EFFECT GI: Diarrhea, Constipation, Gas or Bloating.

CNS: Headache, Dizziness, Nervousness.
EENT: Ringing in the ears

NURSING  Discontinue drug promptly if diarrhea, dark stools,

RESPONSIBILITIES hematemesis, ecchymoses, epistaxis, or rash occur
and do not use again. Contact physician.

 Notify physician if persistent GI discomfort, sore

throat, fever, or malaise occur.
GENERIC NAME FERROUS SULFATE
CLASSIFICATION
DOSSAGE 500MG
ROUTE ORAL
FREQUENCY ONCE A DAY

MECHANISM OF ACTION Ferrous sulfate facilitates oxygen transport via Hb. It is used
as iron source as it replaces iron found in Hb, myoglobin
and other enzymes.

INDICATIONS Treatment and prevention of iron deficiency anemia.

CONTRAINDICATIONS Anemia not related to iron deficiency where there is

intolerance to iron, and inability to absorb it. GI disease or
any iron absorption disease.

SIDE EFFECT GI irritation, abdominal pain with nausea and vomiting,

diarrhea or constipation, black stools.

NURSING 1.) Drink iron supplements with orange juice for proper
RESPONSIBILITIES absorption or in an empty stomach.

2.) Prohibit taking medication with milk.

3.) Encourage patient to increase fiber in diet.

4.) Informed patient that blackening of stool is a normal

reaction to medication but if doubtful to the situation ask
physician for further management.
 DISCHARGE PLANNING

HEALTH TEACHING
 The patient should be aware of any restrictions on exercises or activity that she
needs to follow such as: Do not exercise when blood sugar level is less than
100mg/dl.
 Encouraged patient to have a regular exercise, if not contraindicated to ensure
wellness.

TREATMENT
 Continue home medication such as hypoglycemic agent.
 Educate patient about the purpose of each drug.
 Instructed patient to take prescribed medication at the right time and duration.
 Emphasized the importance of medication compliance.
 Monitor blood glucose level.
 Emphasized the rehabilitation through exercise and compliance of proper diet.