Patient Y's Case Summary

During Patient Y’s stay on the maternity unit, various laboratory studies were drawn via the patient’s blood sample. After arriving on the unit, Patient Y had routine blood drawn, which includes a rapid plasma regain (RPR), CBC and differential, and a type and screen. Please refer to Appendix B. The RPR was drawn to test for syphilis, which is a sexually transmitted disease. Patient Y’s RPR was nonreactive, which indicates that she does not have syphilis. Patient Y’s CBC and differential was within the normal limits, besides her hemoglobin, which was 11.4 g/dL. Since her hemoglobin was a little low routine blood work will be drawn the day after her delivery to recheck her hemoglobin and to make sure she did not lose too much blood. Her blood type was confirmed to be O negative.
While in the labor room, Patient Y was placed on a fetal heart monitor and a toco monitor. The fetal heart monitor recorded the fetus’s heart rate and the toco monitor measured the frequency of her contractions. Patient Y’s vital signs were also monitored throughout this time. After these monitors were placed, the physician performed a cervical exam to determine the engagement of the fetus and the cervical dilation and effacement. The patient was three centimeters dilated, 60% effaced, and at -2. Her membranes were
still intact at this point. Shortly after the cervical exam, it was noted that the fetal heart rate began to decrease. The physician was immediately called and he applied a fetal scalp electrode to more precisely measure the heart rate. Following the application of the fetal scalp electrode, the heart rate was still reading in the low 50s. Due to this finding, the physician called an emergency cesarean section.
After the cesarean section was complete and the patient’s incision was closed, the nurse asked the physician if they were going to order an X-ray of the patient’s abdomen.
The reason why an X-ray would be needed is because there was no initial or final count. This means that when the cesarean section began, the instruments and the sponges were not counted. Due to this they couldn’t have a final count to determine if any instruments or sponges were left in the patient. In order to confirm that there was nothing left inside the abdomen, an X-ray was performed. The physician received the results and no instruments or sponges were left in the patient after the incision was
closed. A postpartum rhogam and CBC and differential were drawn the following day after her cesarean section. Please refer to Appendix C. Patient Y’s hemoglobin dropped slightly following her cesarean section. It dropped to 9.2 g/dL, but this is considered a normal finding. No interventions were needed. Following the cesarean section, a sample of the arterial cord blood was sent to the lab. Please refer to Appendix D. These values indicated that fetal hypoxemia was present. The HCO3 and the base excess values were low and the pO2 value was high. The neonatologist read these values and determined that the fetus suffered from Hypoxic Ischemic Encephalopathy and decided to perform hypothermia treatment, which is brain cooling for three days. Hypoxic Ischemic Encephalopathy is defined as a “clinical manifestation of disordered neonatal brain function in the term infant in the early neonatal period associated with intrapartum hypoxia” (Rossouw, Irlam, & Horn, 2015). Due to the fact that the newborn was admitted to the NICU, the labor nurse transferred his care to a NICU nurse and no more information regarding his medical condition was released.