12.7 Spotlight Application

Background Information: Brianne delivered Marcus, a male infant, vaginally. Marcus experienced complications of shoulder dystocia during delivery.^[1]

Key Data

• APGAR Score: 5 at 1 minute, 9 at 5 minutes
• Birth Weight: 3995 g (8 lbs 14 oz)
• Length: 21 inches (52.5 cm)

Maternal History

• Medical History: No current medications, negative STI history, no surgeries or previous pregnancies.
• Social History: Lives in a two-bedroom apartment on the second floor with a small dog.
• Prenatal History:
  • Blood Pressure: 118-128/64-80
  • Fundal Height at 36 weeks: 40 cm
  • Gestational Diabetes: Yes
  • Age: 36 years, G1 P1
  • Allergies: No known allergies

Delivery Summary

• Labor Duration: 20 hours
• Delivery Complications: Mild shoulder dystocia
• Blood Loss: 450 mL
• Laceration: Second-degree, repaired

Immediate Care

• Marcus was dried off, placed on Brianne’s chest for skin-to-skin contact, and covered with a warmed blanket.

Newborn Assessment (at 30 minutes of age)

• Temperature: 97.8°F (axillary)
• Heart Rate: 160 bpm
• Respirations: 66 breaths per minute (shallow, irregular)
• Pulse Oximetry: 92%
• Color: Pink with acrocyanosis
• Nasal Flaring: Present
• Capillary Glucose: 42

Provider’s Orders

• Observation: In Labor and Delivery unit
• Vital Signs: Every 30 minutes ×2, then hourly ×2, and then every four hours
• Medications:
  • Erythromycin ointment to both eyes within 1 hour of birth
  • Phytonadione 1 mg IM anterior thigh within 1 hour of birth
• Supportive Measures: Encourage skin-to-skin contact, breastfeed on demand, monitor intake and output, initial bath at four hours of age.

Questions

1. What specific signs in Marcus’s assessment at 30 minutes indicate he is experiencing respiratory difficulty?

The specific signs from Marcus’s assessment at 30 minutes that indicate he is experiencing respiratory difficulty are respirations of 66, pulse oximetry of 92%, shallow and irregular respirations, nasal flaring, and lack of interest in nursing.

2. Among the following data points from the assessment, which is the most concerning?

a. Respirations of 66

b. Pulse oximetry of 92%

c. Nasal flaring

d. Capillary glucose of 42

c. Nasal flaring. Rationale: Nasal flaring is a key indicator of increased respiratory effort and potential distress.

 3. Considering Brianne’s history of gestational diabetes, what potential implications could this have on Marcus’s immediate care?

Gestational diabetes may increase the risk for metabolic issues, including hypoglycemia in the newborn. Close monitoring of Marcus’s blood glucose levels is crucial.

4. What immediate nursing interventions should be prioritized for Marcus based on his current condition?

• Monitor vital signs closely, particularly respiratory status and oxygen saturation.
• Provide supplemental oxygen if pulse oximetry remains below normal thresholds.
• Continue skin-to-skin contact to promote thermoregulation.
• Initiate breastfeeding as soon as he shows interest.

5. Explain the significance of Marcus’s APGAR score of 5 at 1 minute and 9 at 5 minutes.

An APGAR score of 5 at 1 minute indicates that Marcus needed some assistance in adjusting to life outside the womb. A score of 9 at 5 minutes suggests significant improvement, reflecting adequate respiratory effort, heart rate, muscle tone, reflex response, and skin color.

6. What long-term health considerations should be discussed with Brianne regarding Marcus’s delivery complications?

The parents should be informed about potential risks associated with shoulder dystocia, such as brachial plexus injury, as well as the importance of regular pediatric follow-up to monitor Marcus’s growth and development.