Introduction
Sally Thomas is a twenty three years old mother and is comprehensively covered in this clinical scenario. The scenario covers aspects of her family history which are of essence to any medical decisions associated with any clinical procedure. The aspect of her past pregnancies will be comprehensively articulated in the case study. Her medical history will be analyzed and clinical solutions proposed for her problems. It is pertinent to note that the scenario will be comprehensive and will articulate each stage of the pregnancy. The scenario will be broken down into multiple sub section which includes the ante partum, fetal development, labor and delivery, post-partum and the new born.
Medical history
Sally Mary Thomas twenty three year old lady is a mother of one. The child was born with sickle-cell anemia. The other pregnancy was terminated by a miscarriage at the first trimester of the pregnancy. Sally was diagnosed with sickle cell anemia as a child and thanks to the medical advancement in the area she underwent treatment which has allowed living a healthy life. The causes of the miss carriage are unclear but it is suspected that it was caused due to fatigue and heavy work. It is pertinent to note that the sickle cell disease is a disorder that is usually genetic based. This implies that Sally’s child inherited the disease from the parents. The condition is associated with painful periods as well as the risk of suffering from chronic anemia. Early diagnosis of sickle cell anemia will trigger adequate treatment at the early stage. This will allow children to live a relatively productive live regardless of their condition.
In her first pregnancy Sally had suffered painful episodes associated with sickle cell anemia. The miscarriage was also associated with the condition apart from the link to her occupation. A month before the birth of her first child she reported preterm labor which triggered a close medical monitoring during her last trimester of the pregnancy. Just before the delivery of her child she was offered preconception counseling to equip her with information regarding the complications brought about by her abnormality. Moreover, this was enhanced with information during post natal clinics where she was also offered preconception advice regarding conditions that would affect her future pregnancies.
Family history
Sickle cell anemia was also present in the family of Sally with her mother reportedly suffering from the abnormality. Moreover, the mother was diagnosed with chronic anemia at her forties. She also suffered from serious infections that were associated with the abnormality.
- Ante partum
Sally underwent the routine antepartum care procedures.
EDD: the estimated date of delivery was deduced as 30th September 2013. Trimester
She attended seventy percent of the routine prenatal care visits. The visits are instrumental in enhancing the nutritional educational, medical as well as the psychosocial needs of the patient.
Initial prenatal care
During the first trimester Sally attended her first prenatal care visit. Some of the key aspect covered during this visit was filling in a questionnaire that captured her medical history and basic details. Moreover, the family history as well as the psychosocial environments she lived in was identified. It is at this point that her sickle cell anemia condition was first captured during this pregnancy. A pelvic examination was conducted and everything was found to be normal at this stage. Moreover, tests to investigate existence of any chlamydia or gonorrhea infection. This was through a pap and culture smear. Assessments on the cervix, adnexa, uterus as well as the gestational age were instrumental in determination of the complexity or normalcy of the pregnancy.
At this stage of the pregnancy multiple blood studies were conducted. These included Rh screening, blood type test, as well as antibody screening. Tests conducted to identify presence of conditions included serologic tests for HIV, rubella as well as hepatitis B. Other tests carried out at this stage included glucose screening for macrosomia, urine protein screening for asymptomatic bacteriuria as well as hemoglobin electrophoresis for sickle cell anemia. At this stage it was confirmed that Sally had sickle cell anemia. Sally was offered advice regarding medications, vaccination and crisis mitigation due to her condition (Provan, & Singer, 2009).
At this, stage of the pregnancy the haemogloninopathy status of the partner was required to make informed decisions during the pregnancy. After this was conducted it was clear that the couple was at risk in regard to sickle cell anemia. Genetic counseling was availed to both partners.
Some of the key information provided to Sally due to her sickle cell abnormality included:
- Avoid factors that trigger sickle cell crises these factors include but not limited to rapid dehydration, exposure to high temperatures as well as overexertion.
- In case there is an incidence of persistent vomiting a medical practitioner should be consulted.
- Influenza vaccine was also recommended if none was administered to Sally in the past year.
Discomforts
The discomforts reported as the first trimester of the pregnancy was reported included prolonged abdominal problems, chest problems as well as fatigue. After further investigations it was discovered that she was suffering from an infection caused by Streptococcus Pneumonia. Daily penicillin prophylaxis doses were administered to her for the recommended time. Low dose aspirin was admixture at the 11th week of pregnancy to minimize the risk of pre-eclampsia development. During the 23rd week of the pregnancy Sally became unwell with multiple symptoms presenting at different times. On arrival to hospital it was discovered that she had an acute painful crisis associated with her sickle cell condition. She was assessed promptly and appropriate analgesia administered. Moreover, she was also given thromboprophylaxis to stabilize her situation. As her situation changed Laxatives were prescribed and analgesia reduced. By the third day of hospitalization the injections were changed with an oral dosage of analgesia. She was discharged from hospital on the fifth day and a follow appointment booked after a week.
Warning signs
Apart from the routine antenatal care that pregnant women are offered extra precautions were taken when handling Sally who had sickle cell disease. Some of the warning signs clearly communicated to her included. Incidence of continuous vomiting, continuous fatigue, as well as, vaginal discharge. To take precautionary measures with regard to this warning sings regular blood pressure checks were recommended. Moreover, urinalysis was performed on regular basis. Other warning signs of hypertension were closely monitored to ensure that the risk of pregnancy induced hypertension is averted.
Nutrition for mother and fetus
Nutritional advice that was provided was instrumental to the fetal development process. Moreover, vitamin supplements were provided for use on a daily basis. Folic acid is instrument in the development of the neural parts of the unborn baby. Moreover, the consumption of the recommended amounts of folic acid prevents the occurrence of neural tube defects.
Visit procedures in each trimester
First trimester:
- Initial antenatal visit
Second trimester:
- Routine clinical visit
During this visit several screening were conducted these included:
- Karyotype screening
- Amnio screening
- Ultrasound screening
- Multiple markers screening
Third trimester: during the third trimester three routine visits were scheduled:
- Clinic visit at the 28th week.
This was the first clinic visit during the third trimester:
The following tests were performed during this visit.
- D (Rh) Antibody screening
- Gestational diabetes screening GCT screeningSection 2) General fetal development
At this stage an anti-D immune Globin (RhIG) was administered.
Routine clinical visit at the 36th week
This was the second visit during the third trimester and involved several tests as well as nutritional and medical advice. The test carried out included:
- Hct/Hgb
- Gonorrhea
- Chlamydia
- Ultrasound
- Group B strep
At this stage of the pregnancy a comprehensive review of the fetal growth is pertinent. This is important in identifying the concerns, as well as, the warning signs of a hypertension of complications during birth. Sally was also offered advice in multiple aspects such as mode, timing as well as management of birth. She was also given information regarding anesthesia, analgesia as well as appropriate baby care. A comprehensive anesthesia assessment was performed during this visit. It is pertinent to note that Sally had sickle cell disease and care must be taken to ensure that the safety of the child as well as the mother is enhanced.
Fetal development norms
Fetal developments norms are the beliefs that a patient or the society may have regarding pregnancies. There are multiple norms that Sally has regarding the best way to handle a pregnancy for optimal fetal developments. She believes that sickle cell anemia her child developed was as a result of her taking specific types of foods during her past pregnancy. Moreover, she believes that the loss of her first pregnancy was as a result of her occupation. She also believes that the aspect of fetal neurological development is significantly influenced by the mood she is in during the time of the pregnancy. On the other hand the impairment of growth of her child is a risk she thinks is affected by her current weight. The belief that the cognitive abilities of a child are highly associated with factors such as trauma and stress that may result to any form of impairment of fetal development (Pickett, & Gurenlian, 2010).
Section 3) Labor and delivery,
At the end of the 38th week of gestation Sally visited an obstetrician and a midwife who recommended that she undergoes caesarean section at the end of the 40th week of gestation. The EDD was indicated as 30th September. It is pertinent to note that the hospital selected for the delivery process was well equipped and resourced to handle complications associated with sickle cell disease patients. During labor adequate fluid and appropriate temperatures were maintained. Moreover, monitoring of the heart rate through an intrapartum electronic device was used to monitor occurrence of fetal distress. Due to the risks that exist for SCD cases undergoing a protracted labor adequate observation by a multidisciplinary team was put in place. During her third hour of labor it was observed that oral hydration was not adequate and intravenous fluids used. However, to prevent the occurrence of a fluid overload a fluid balancing chart was used. The risk of hypoxia was heightened by the prolonged labor and steps had been taken to mitigate this risk. A pulse oximetry was used due to increased demand for oxygen during this period. When an arterial blood gas analysis was performed it was found out that the saturation level was at 96 percent. This negated the necessity for an oxygen therapy.
At her third trimester of pregnancy a comprehensive anesthetic assessment had been carried out on Sally making it easy for administration. In this case Sally was subjected to regional analgesia. This is because the use of general anesthesia poses a great risk to a patient with sickle cell disease.
The delivery was through a caescerian section. Close monitoring of the patient during delivery and after delivery is important to ensure that she was out of danger. The maternal blood oxygen level was maintained at 95 percent saturation. Moreover, the fluid balance chart was used to ensure the adequate hydration was available. After delivery Sally was advised to use antithrombotic stockings.
Section 4) Post-partum,
The post-partum visit was scheduled at the 8th day after delivery. This is because the delivery was through a caesarean section. Some of the physical assessments conducted during this visit included weight, blood pressure, abdomen as well as breasts. Moreover, a pelvic examination as well as episiotomy repair was conducted during this visit. During the visit Sally was advised on various areas including but not limited to birth control, postpartum depression, breast feeding and how to assess the adaptation of the new born.
The postpartum family planning advice was offered to Sally. Some of the options that she was informed that would be effective with her included: contraceptives containing progestogen, levenorgestrel intrauterine as well as injectable contraceptives (Monsen, 2009).
Section 5) Newborn,
The newborn was born weighing 2.7 kg and was male in gender. This was ascertained after a comprehensive physical examination was performed on it. Some of the physical examinations performed on the baby included but not limited to hearing screen through an auditory brain stem response test. Several other prophylactic procedures were performed on the new born. The significance of these procedures is purely protective in nature. The first treatment is the aspect of blood typing. This is to identify the blood group of the child. The blood is obtained from the umbilical cord. The newborns eyes are at risk of inflation as a result of bacterial infection. To prevent this erythromycin ointment is put into the eyes of the new born. To prevent bleeding as a result of inadequate prothrombin vitamin K was administered just five hours after delivery. The pulse oximetry test was performed to ascertain the level of oxygen in the blood of the new born.
Genetic screening of the newborn was also performed. Some of the genetic disorders that are pertinent to know at an early stage include phenylketonuria. Other tests that was performed on the baby included thalassemia and galactosemia. Administering different types of vaccines was also a pertinent aspect before Sally and the newborn were discharged from hospital.
References
Monsen, R. B. (2009). Genetics and ethics in health care: new questions in the age of genomic health. Silver Spring, Md.: American Nurses Association.
Pickett, F. A., & Gurenlian, J. R. (2010). Preventing medical emergencies: use of the medical history (2nd ed.). Baltimore, MD: Lippincott Williams & Wilkins.
Provan, D., & Singer, C. R. (2009). Oxford Handbook of Clinical Haematology (3rd ed.). Oxford: OUP Oxford.
