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Risk factors associated

Providing a Comprehensive Evaluation of the Post-Operative Postnatal Progress and Care of the Woman.

The prenatal and postnatal care or the lack thereof for the women who have had Caesarean section and are pregnant again for the second time or have experiences complications during the surgery is a major public health priority, especially for the single woman. One of the major complications that the pregnant women face in the current times is the preterm labour or premature delivery. Preterm labour can be defined as the phenomenon when the baby is born before the 37 weeks of gestation is completed, there can be various contributing factors leading to preterm labour like recurrent preterm birth, extreme anxiety or stress, excessive smoking, cervical exhaustion, infections, etc. The rate of preterm birth has been increasing rapidly, and just in the past decade the rate has jumped close to 30% (MacIntyre et al., 2012).

This case study selected for this assignment explains in detail about the medical history of the Yvette, who have had two previous preterm births and is in preterm labour again with various other complications. The woman under consideration in the case scenario had been a heavy smoker and had been caring for two children singlehandedly. Along with that, she had been suffering with whooping cough, UTI and several other infections while in 32 weeks of gestation and had to be admitted to the hospital where she underwent LSCS (Khan et al., 2010). This assignment will attempt to explore the risk factors associated with such scenarios, design a care plan for the newborn and formulate a midwifery care plan for the woman as well.

According to the case study, the mother, was 32 weeks in gestation and was admitted to the hospital facility, with symptoms like abdominal pain, dysuria, and mild contractions occurring for two days. The medical history includes Group B streptococcus positive urinary tract infection at 26 weeks of pregnancy as well. Along with that her previous two children were both born prematurely close to two years apart; Yvette is extremely stressed and is a heavy smoker with 20 cigarettes a day, and her premature labour is tensing her further. Based on the finding of this case study the two major risk factors that could have positively contributed to her premature labour are smoking and her past history of recurrent preterm births (MacIntyre et al., 2012).

Care plan for Sam


There are a variety of adverse effects of smoking on the health and wellbeing of a normal individual, in case of pregnancy however; the risk factors increase multiple folds. According to a large number of exploratory study, smokers were found to be on an elevated risk of pre term delivery, along with that, the risk for preterm birth increased with the increase in number. For instance, heavy smoker mothers had the greater risk of 24% for very preterm labour, 28% for spontaneous birth, and 28% of medically indicated preterm labour. However, the exact pathway through which smoking escalates the risk for preterm birth is not completely known yet (Khan et al., 2010). Although extensive research has discovered that excessive concentration of nicotine and carbon monoxide in the system, compromising the placental blood flow, which in turn disrupts the vasoconstriction of the placental vessels. Along with that the carbon monoxide present in the tobacco smoke is also known to produce carboxy- hemoglobin interfering with the fetal oxygenation (Tsiartas et al., 2012). The nicotine accumulated in the body system of a smoker is also known to increase the maternal blood pressure and pulse rate, which in turn restricts the blood flow to the fetus. The culmination of all these factors ultimately results in altering the amniotic environment for the fetus and restricts the growth and development of the fetus, leading to the preterm labour; idiopathic preterm labour is also associated with the excessive smoking in pregnant woman and is rightfully considered one of the biggest risk factors to preterm delivery in woman (Olsson, Ahlsén & Eriksson, 2016).

Another highly impactful risk factors in this case scenario that could have contributed to Yvette having to undergo third preterm birth by the means of lower segment caesarean section is her past history of recurrent preterm labour. Recurrent labour can be defined as the occurrence of two or more births before the 37 weeks of gestation can be completed. Various studies have suggested that the occurrence of previous spontaneous preterm labour increases the risk of the next pregnancy to be preterm as well, however in case of preterm labour associated with preeclampsia, the statistics may vary (Pryhuber et al., 2015). Hence it can be suggested that her previous history of premature birth following preeclampsia followed by second premature delivery due to preterm labour increased the risk factor for her indicated preterm pre labour rupture of membranes or PROM. Authors have discussed the cervical insufficiency resulting from the occurrence of more than one preterm delivery to be the contributing factor behind the indicated recurrent preterm labour (Henderson et al., 2012). Cervical insufficiency is the result of early cervical ripening caused by the loss of connective tissue or intrauterine infection which has been present in case of the woman under consideration. Therefore it can be concluded that the post operative cervical ripening due to more than one preterm surgical delivery has been one of the greatest risk factors for Yvette, and coupled with excessive anxiety, smoking, and infections propelled her towards her third PROM (Russell et al., 2014).

Currently, the newborn baby Sam is undergoing investigation in nursery, as he is a premature baby. He is also undergoing treatment for acute infection. Sam is at increased risk of infection owing to the immunological immaturity and the UTI infection from mother. In addition to infection the preterm babies are at risk of respiratory distress, hypothermia and hyperthermia due to ambient temperature changes. According to Drysdale et al. (2014), respiratory distress is related to lung immaturity and low surfactant produced. The premature babies are also at risk of impaired sensory, auditory functions.

Thus, the care plan for Sam include the following –

To ensure thermal homeostasis the infant will be placed in the warmer and isolette incubator and ensure that the baby has appropriate clothing. The carer may dry Sam thoroughly and discard the wet blanket soon. This process may prevent heat loss from evaporation. The baby must not be positioned on close surface. Sam may have cold stress due to hypothermia and hyperthermia may cause respiratory distress, thus regular monitoring of the temperature is needed. The care provider must provide medication as prescribed to prevent seizures associated with hypethermia (Drysdale et al., 2014).

The breast milk can be instilled that is the expressed breast milk (EBM) to maintain body nutrients. It is because Sam may be at risk of imbalanced nutrition as a consequent of low glucose, iron and calcium reserve in the premature baby. As the premature babies have high rate of metabolism and inadequate calorie intake, they have low glycogen stores. Thus, it is mandatory to assess the input and output as well as blood sugar level (risk of hypoglycemia), weight and serum sodium (Green et al., 2015). The baby will be nil by mouth and on IV therapy to restore fluids. As the baby preterm, the careers must insert the nasogastric tube. The rationale for this is the premature babies, who are also prone to fluid and electrolyte imbalances caused by environmental factors and loss through lungs, skin,urine and skin. In case of edema, the fluid volume should be adjusted accordingly. Usually the preterm babies can concentrate urine to ~ 600 mOsm/L (Green et al., 2015).


The baby must be regularly assessed for the BP, TPR and ascultate breath sounds to track the spread of infection. Therefore, the baby must be monitored for fever, vomiting, jaundice, urine with blood, cloudy urine or unpleasant-smelling urine. Since the baby already have an acute infection, there is a need of antibiotic therapy (IV antibioticss) as it inhibits the growth of bacteria. The UTI infection is usually treated within two to three days. Until the infection is cured breast, milk should be stopped to void further infections. Further, there is a need of identification and treatment of the voiding dysfunction. Evaluating the condition and based on the child’s clinical judgment, the imaging evacuation of the urinary tract can be individualised. The UTI infection from mother can impose the risk of kidney in Sam. Thus, the baby must be  assessed for the Kidney function (Vachharajani et al., 2015).

It must be ensured in the nursery that all the people coming in contact with the baby maintain hand washing protocol to prevent infection. Sterilised equipments should be used to make necessary assessments (Olsson et al., 2016). Further, the neonate must be monitored for the  signs of poor skin turgor, dehydration, ad sunken eyeballs for medical intervention. The baby’s eyes must be covered with patches while under the phototherapy lights to prevent retinal damage. Regular inspection of eyes is necessary to facilitate treatment for purulent conjunctivitis. The care provider in the intensive care unit must position Sam on side with rolled blanket at his back as this position facilitates breathing.  As per Pryhuber et al. (2015), immaturity also leads to fragile skin. To prevent the superficial burns on skin avoid oily applications and repositioning is needed every two hours to avoid pressure areas (Russell et al., 2014).

Lastly, the mother should be trained on the implications of the infection and the precautions to be taken to avoid further infections. Proper guideline must be given regarding care, handling of the baby and nutrition and the symptoms that need immediate medical intervention. 

Preterm birth is considered to be one of the most common pregnancy related complication ad a vast majority of the young mothers suffer from this particular complication. Although a preterm delivery is generally highly complicated and there are a number of risk factors associated with the preterm labour (Mercer, 2012). Hence even after the delivery, the preterm birth mothers face dire need of ongoing care and support both medical and psychological from the post natal care providers. Although the nursing acre professions will assist the woman with the pharmacological care needs and requirements the midwives can help the mother deal with other related complications after the preterm birth that will help her recover faster and care for herself and her child much better.

One of the greatest challenges that a mother post preterm delivery include the infection, pain, confusion, anxiety, and most of helplessness in controlling her grievances. The midwives can provide immense psychological support along with guiding the mother with the care needs of herself and her baby. He care and management that Yvette will receive from the post natal obstetric staff or midwives in particular, include kangaroo care, postpartum pain management, psychological and social support including anxiety management, successful lactation, family centred care and guidance for planning future pregnancy (Lamont et al., 2011).

Kangaroo care can be defined as the skin to skin contact of the mother with her newborn dressed only in a cap and diaper, and for the preterm babies in the neonatal intensive care unit, this technique is highly beneficial facilitating improved breastfeeding rates, stable body temperature for the new born, decreased hospital stays, and improved neurological development of the newborn (Di Renzo et al., 2011).  And as the preterm babies lack in body weight and slow growth rates, this technique is even more beneficial for the preterm babies. In this technique the midwife will train Yvette to hold her neonate on her chest providing skin to skin contact which will regulate the baby’s body temperature decreasing the risk for preterm hypothermia and will train the other in readily accessible breastfeeding when need be.

The second support that the woman under consideration for the assignment will receive from the midwives is regarding post partum pain management which is a very common occurrence following a LSCS (Flenady et al., 2013). The immediate relief intervention that the woman can achieve include lateral recumbent position, relaxation techniques like breathing exercises, back rubs, therapeutic touch exercise and administration of mild analgesics as directed by the registered midwife.

Successful lactation is one of the most vital parts of the post natal care management and for good health of both the mother and the newborn. According to the American academy of paediatrics, the human milk is absolutely necessary for adequate growth and development of the baby. Although the mothers that give preterm deliveries face the challenge of successful lactation and maintaining adequate milk supply. The midwife can train Yvette the hand pumping technique to increase the milk supply, along with monitoring the breast health and milk production of the mother regularly to avoid mastitis or candidiasis as consequences of excessive pumping. Periodic breast massage is also a caring tactic that midwives take in order to help the preterm mothers increase their milk production rate (Flenady et al., 2013).

Post partum depression and anxiety has emerged as one of the major maternal health and wellbeing priorities and Yvette, the woman under consideration for this assignment has already been dealing with excessive stress, anxiety and depression while being a single mother with two infants and a neonatal newborn, psychological support is one of the mandates in this situation. In case of NICE screening for postnatal anxiety and depression is one of the mandatory protocols; though there is not much for the midwives to do in clinical care, therapeutic management can be given to Yvette effectively by midwifery professional. Counselling and relaxation therapies engaging active communication and compassionate support can help the mother overcome her depression and fears and concentrate on keeping herself and her child healthy (Neilson, West & Dowswell, 2014).


Lastly overall guidance and training for preplanned future pregnancy and social support given by the midwife to the preterm mother, Yvette for this case scenario, has been proven to reduce the risk of post partum depression and anxiety along with the risk of recurrent preterm birth. The midwife will engage Yvette in a proper woman education regarding the risk factors of safe time gap between the next pregnancy and contraceptive techniques ensuring the best health for the mother and her children at large (Wylie et al., 2011). Proper social support of counselling and day care for her children, while she is in the hospital, will also be discussed with Yvette by the midwife.

However, there are a few precautionary assessments that the midwife will engage the woman because of the infections that she had been suffering with. As per the case study, there is need for a few blood tests needed for testing the infection status of the whooping cough and the group B streptococcus infection like the CBC or complete blood count test. The temperature of the woman needs to be monitored periodically because of her infections. As Yvette has had whooping cough before the delivery, the midwife will also need to restrict the woman from visiting the newborn until all her infections are reduced. For her C-section, the incision site will be monitored regularly by the midwife for any signs of infection and any irregular bleeding should be monitored diligently as well, along with any impending fever.

Conclusion:

On a concluding note, it can be stated that the rate of preterm births have been increasing a at a rapid rate over the years and there are a myriad of risk factors that facilitate the preterm labour in women. For instance, in this case scenario where Yvette had suffered through two previous preterm deliveries and different infections and had to suffer through another preterm birth followed by a LSCS surgery. The anxiety and fear that Yvette had been experiencing had been very natural given the circumstances she went through as a single mother without any support, although continuing smoking had been one of the major contributing factors that propelled her towards the complications for the most part.

However, it must not escape notice that optimal compassionate care and support has the potential to help her overcome the crisis situation and attain speedy recovery for both herself and her premature child. This assignment has discussed three of the key factors associated with the premature birth in the current age, the risk factors contributing to preterm birth, the postnatal care and management for the neonate and post natal care and management for the mother. It can be hoped that the care techniques and management outlined in the assignment will be beneficial in helping Yvette gain proper health in no time along with her newborn child.

References:

Di Kenyon, S., Boulvain, M., & Neilson, J. P. (2010). Antibiotics for preterm rupture of membranes. Cochrane Database Syst Rev, 8(8).

Di Renzo, G. C., Roura, L. C., Facchinetti, F., Antsaklis, A., Breborowicz, G., Gratacos, E., ... & Radunovic, N. (2011). Guidelines for the management of spontaneous preterm labor: identification of spontaneous preterm labor, diagnosis of preterm premature rupture of membranes, and preventive tools for preterm birth. The Journal of Maternal-Fetal & Neonatal Medicine, 24(5), 659-667.

Drysdale, S. B., Alcazar, M., Wilson, T., Smith, M., Zuckerman, M., Lauinger, I. L., ... & Greenough, A. (2014). Respiratory outcome of prematurely born infants following human rhinovirus A and C infections. European journal of pediatrics, 173(7), 913-919.

Flenady, V., Hawley, G., Stock, O. M., Kenyon, S., & Badawi, N. (2013). Prophylactic antibiotics for inhibiting preterm labour with intact membranes. The Cochrane Library.

Green, J., Darbyshire, P., Adams, A., & Jackson, D. (2015). Looking like a proper baby: nurses' experiences of caring for extremely premature infants. Journal of clinical nursing, 24(1-2), 81-89.

Henderson, J. J., McWilliam, O. A., Newnham, J. P., & Pennell, C. E. (2012). Preterm birth aetiology 2004–2008. Maternal factors associated with three phenotypes: spontaneous preterm labour, preterm pre-labour rupture of membranes and medically indicated preterm birth. The Journal of Maternal-Fetal & Neonatal Medicine, 25(6), 642-647.

Lamont, R. F., Nhan-Chang, C. L., Sobel, J. D., Workowski, K., Conde-Agudelo, A., & Romero, R. (2011). Treatment of abnormal vaginal flora in early pregnancy with clindamycin for the prevention of spontaneous preterm birth: a systematic review and metaanalysis. American journal of obstetrics and gynecology, 205(3), 177-190.

MacIntyre, D. A., Sykes, L., Teoh, T. G., & Bennett, P. R. (2012). Prevention of preterm labour via the modulation of inflammatory pathways. The Journal of Maternal-Fetal & Neonatal Medicine, 25(sup1), 17-20.

Mercer, B. (2012). Antibiotics in the management of PROM and preterm labor. Obstetrics and Gynecology Clinics, 39(1), 65-76.

Neilson, J. P., West, H. M., & Dowswell, T. (2014). Betamimetics for inhibiting preterm labour. The Cochrane Library.

Olsson, E., Ahlsén, G., & Eriksson, M. (2016). Skin?to?skin contact reduces near?infrared spectroscopy pain responses in premature infants during blood sampling. Acta Paediatrica, 105(4), 376-380.

Pryhuber, G. S., Maitre, N. L., Ballard, R. A., Cifelli, D., Davis, S. D., Ellenberg, J. H., ... & Ren, C. (2015). Prematurity and respiratory outcomes program (PROP): study protocol of a prospective multicenter study of respiratory outcomes of preterm infants in the United States. BMC pediatrics, 15(1), 37.

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Russell, G., Sawyer, A., Rabe, H., Abbott, J., Gyte, G., Duley, L., & Ayers, S. (2014). Parents’ views on care of their very premature babies in neonatal intensive care units: a qualitative study. BMC pediatrics, 14(1), 230.

Sweet, D. G., Carnielli, V., Greisen, G., Hallman, M., Ozek, E., Plavka, R., ... & Halliday, H. L. (2013). European consensus guidelines on the management of neonatal respiratory distress syndrome in preterm infants-2013 update. Neonatology, 103(4), 353-368.

Tsiartas, P., Holst, R. M., Wennerholm, U. B., Hagberg, H., Hougaard, D. M., Skogstrand, K., ... & Jacobsson, B. (2012). Prediction of spontaneous preterm delivery in women with threatened preterm labour: a prospective cohort study of multiple proteins in maternal serum. BJOG: An International Journal of Obstetrics & Gynaecology, 119(7), 866-873.

Vachharajani, A., Vricella, G. J., Najaf, T., & Coplen, D. E. (2015). Prevalence of upper urinary tract anomalies in hospitalized premature infants with urinary tract infection. Journal of Perinatology, 35(5), 362.

Van Der Ham, D. P., Vijgen, S. M., Nijhuis, J. G., Van Beek, J. J., Opmeer, B. C., Mulder, A. L., ... & Bloemenkamp, K. W. (2012). Induction of labor versus expectant management in women with preterm prelabor rupture of membranes between 34 and 37 weeks: a randomized controlled trial. PLoS medicine, 9(4), e1001208.

Wylie, L., Hollins Martin, C. J., Marland, G., Martin, C. R., & Rankin, J. (2011). The enigma of post?natal depression: an update. Journal of psychiatric and mental health nursing, 18(1), 48-58

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