This case study involves Sara, a 35 year old Hispanic woman presenting for prenatal care at 24 weeks gestation. She has risk factors for gestational diabetes including a family history. Sara is diagnosed with gestational diabetes after failing her 3 hour glucose tolerance test. During her induction of labor at 38 weeks, she experiences dysfunctional labor likely due to macrosomia. Despite efforts, late decelerations develop requiring an emergency c-section for fetal distress. Her baby boy Michael is born weighing 9 pounds 8 ounces.

2. Upon completion the student will be able to:
 Identify the risk factors for developing gestational
diabetes
 Explain the oral glucose tolerance test
 Discuss education provided for preterm labor
 Identify basic characteristics of a monitor strip
 Discuss the causes of dysfunctional labor
 Analyze how and discuss why the patient had this
particular outcome

3.  Each group is expected to participate during
the case study.
 Each group has been provided with a set of
cards and a history sheet with important
information about the patient.
 As the case unfolds the groups will be
presented with questions, answer to the best
of your abilities. Several questions can have
multiple answers, use the cards provided.
 This case study relates to several important
complications of pregnancy which you have
read about.

4. “The primary objective of nursing care
is to achieve optimal outcomes for
both the pregnant woman and the
fetus” (Lowdermilk, Perry, Cashion,
2010, p. 581)

5.  Sara is a 35 year old
Hispanic-American
woman in her fifth
pregnancy. She is
presenting for prenatal
care at approximately 24
weeks gestation.

6. You are the nurse assigned to assess the
patient and take a history
 5’2”, 230lb, unsure of pre-pregnancy
weight
 BP 140/90
 HR 75
 R 20
 Temp 98.7
 Uterine size appropriate for gestational
age

7. G 5 T2 P 2 A 0 L 3
1. 39 weeks gestation – 7 lb 13 oz boy born
vaginally – natural
2. 37 weeks gestation – 8 lb boy born vaginally
– IV medications only
3. 32 weeks gestation FD (fetal demise)
vaginally – epidural
4. 36 weeks gestation 8 lb 10 oz girl born
vaginally – epidural
5. Current pregnancy

8.  Complications:
 Late to prenatal care
 Smokes occasionally, denies illegal drugs or alcohol
 Previous fetal loss at 32 weeks
 Previous preterm delivery
 Previous macrosomia
 Family History:
 Mother of patient diagnosed with Type 2 Diabetes
 Father of patient has HTN and bladder cancer
 Husband was adopted, limited information on his family
 Other information:
 Sara works as a preschool teacher
 She has been tired lately
 She exercises 0-1 times every week

9.  Hgb - 17
 Hct - 40
 Plt - 280
 WBC - 8
 HIV - neg
 Gonorrhea/Chlamydia
– neg
 Pap smear - neg
 Hep B – neg
 Hep C – neg
 RPR – neg
 Blood type – A +
 1 hour Glucola –
150mg/dl
 Urine – neg for
protein or bacteria
 GBS - positive

10. Patient presents for follow up 3 hour OGTT test.
Patient has been NPO for 8 hours and not smoked for
over 12 hours.
The 3 hour Oral glucose tolerance test (OGTT) was
completed due to Sara’s increased risk for GDM and 1
hour OGTT of 150mg/dL. Which of the following
values of her 3 hour OGTT did she fail, indicating a
diagnosis of GDM?
A. Fasting – 110mg/dL
B. 1 Hour – 170mg/dL
C. 2 Hour – 165 mg/dL
D. 3 Hour – 120 mg/dL

11. Sara is diagnosed with Gestational Diabetes. She is
encouraged to change her diet, exercise, stop
smoking, see a diabetes educator, and she is
started on Glyburide.
As her nurse you educate her on the following:
 Take her Glyburide at least 30 minutes prior to a
meal
 Carry a snack
 Check her blood sugar before each meal
 Eat small and more frequent meals
 Avoid high sugar foods
 Call if she develops symptoms
 Keep a log of her diet and blood sugars

12. If Sara had come to you for pre-conceptual
counseling which of the following in the
patients OB history would you tell her puts
her at a higher risk for gestational diabetes?
A. 36 week vaginal delivery 8lb 10oz
B. 32 weeks Intrauterine fetal demise
C. Oligohydramnios with 2 previous
deliveries
D. 39 week vaginal delivery 7lb 13oz

13. Sara calls her OB’s office at 32 weeks gestation
complaining of severe gas pains, lower back
discomfort, and urinary frequency. You tell her
to go to the hospital for assessment.

14. Sara is being assessed to determine whether
she is experiencing preterm labor. What
finding(s) would diagnose preterm labor?
A. Fetal Fibronectin is present in vaginal
secretions
B. Irregular, mild uterine contractions
occurring every 12-15 minutes
C. The vaginal exam changes to 2cm/30%/-3
from 0/0%/-3

15. Sara arrives to Labor and
Delivery. You put her on the
monitor and give her fluids. Her
vaginal exam is 1/30%/-3 at 32
weeks. Her membranes are
intact.
Nursing Actions:
• Hydrate the patient
• Obtain a urine sample which is negative for bacteria
• Lay Sara on her left side
• Monitor her for several hours
• Recheck her vaginal exam for change

16. After further monitoring, you note
occasional contractions, and no
change in her cervix. You send Sara
home with discharge instructions
for preterm labor.

17. Sara has demonstrated she understands
your education about preterm labor
symptoms when she states which of the
following?
A. “If I feel cramping I need to drink water, lay on my left
side to see if it will go away”
B. “Only when I have painful contractions am I in preterm
labor”
C. “I need to come to the hospital when my cervix dilates”

18. Sara arrives to the hospital at 38 weeks
gestation for a scheduled induction of labor.
She arrives at 0500 for her induction. She is
placed on the monitors, IV started, labs drawn
and Blood Sugar obtained of 95mg/dL.
Nurse Notes

19. • IV Normal Saline at 125ml/hr
• Pitocin Protocol begun
• Penicillin every 4 hours, due to GBS positive
status
• External monitors
• Blood sugars monitored every 8 hours or if
symptomatic
• Epidural upon request

20. FYI
Oxytocin (Pitocin) is on the list of high-
alert medications designated by the
Institute for Safe Medication
Practices because of the potential to
cause significant harm when used
inappropriately

21. When managing the Pitocin for Sara’s
induction, you should discontinue the
Pitocin immediately if :
A. Uterine contractions occurring every 3-5
minutes
B. A fetal heart rate of 180 with absence of
variability
C. Sara needs to void
D. Rupture of amniotic membranes

22. At 1000:
• The MD arrives and AROM Sara
and we find light meconium stained
fluid. Vaginal exam 2cm/60-70%/-2
• Baby tolerated procedure well
• Mother pain 3/10, denies wanting
pain medications at this time
• Continue to monitor FHR, CTX
• Continue to increase Pitocin per
protocol

23. At 1100:
• Patient states her pain is 6/10
and desires pain medication.
• Vaginal exam reveals
3-4/70%/-2
• FHR reasurring, ctx every 4-5
minutes
• Sara given epidural for comfort

24. At 1400:
• Sara exam is unchanged
3-4/70%/-2
• Ctx every 8-10 minutes on
external monitor
• FHR is 150, moderate
variability, no decelerations
• Vital signs: BP 150/88,
Resp 22, HR 80, Temp 99.1.

25. Based upon your nursing assessment of her
progress, which one of the following
interventions would you do first?
A. Palpate the uterus during a contraction.
When not contracting perform Leopold’s
maneuvers to determine fetal position
B. Go take a quick lunch break while things are
calm
C. Notify physician of current status
D. Do nothing but continue to monitor FHR
and reexamine in one hour

26. • You palpate the uterus and find
the contractions are mild. The
fetal position is determined with
Leopolds and the baby is cephalic
• You notify the MD of no change
in vaginal exam and request an
IUPC.
• You place an IUPC and increase
the Pitocin to get into a good
pattern.

27. ______________ is defined as long,
difficult, or abnormal labor. It is caused
by various conditions with the 5 factors
affecting labor.
A. Augmentation of labor
B. Vaginal birth after cesarean
C. Postterm delivery
D. Dystocia of labor

28. Which of the following is listed as causing
increased risk for labor dystocia?
A. History of preterm labor
B. Height of 5’2” and weight 230lb
C. Hispanic-American
D. Diagnosis of Gestational Diabetes

29. With the information you about her labor
progress, which of these TWO P’s is probably
involved with causing Sara’s dysfunctional
labor?
A. Passenger
B. Pain
C. Power
D. Passageway

30. Based on the patient history which of the
following is the likely cause of the labor
dystocia?
A. Not enough Pitocin, need to increase
B. Needs more pain medication to relax
C. Macrosomia of newborn
D. Dehydration of patient

31. You note the following fetal heart rate
tracing. What does the tracing show?
A. Early decelerations
B. Accelerations
C. Late declerations
D. Variables

32. At 1545:
• Turn the Pitocin off, IV bolus of fluid
• O2 by face mask at 2 liters
• Patient on left side
• Vaginal exam 6/90%/-1
• Notified MD of late decelerations will
continue to monitor FHR with no Pitocin
• Patient has pain of 2/10, updated family on
plan

33. Despite efforts, the fetal heart rate shows a
prolonged deceleration.

34. Due to the fetal heart rate drop and previous non-
reassuring signs you call for an MD, notify NICU of
compromised newborn and need for an operating room
STAT. Sara is taken back for an emergency c-section for
fetal distress

35. Which of the following would you need to report to
the NICU as they prepare to receive the baby in
a STAT situation?
A. Non reassuring fetal heart rate
B. Sara’s vital signs – BP 140/90, R 24, T 98.8, P
100
C. Group Beta Strep positive
D. Light meconium stained fluid

36. Now let us watch the
Emergency C-section
to save baby
How fast do you think they can get baby out?
http://www.medicalvideos.us/play.php?vid=3933

37. Meet baby boy Michael. Michael was born at 1615
by emergency c-section. He weighed 9lb 8oz and
was 22” long. Apgars were 7 and 9. His initial
blood sugar was 35. He required monitoring for
respiratory distress and blood sugars. Today he
is breastfeeding and bottle feeding and is doing
well.

38. At Sara’s 6 week postpartum visit to her OB,
which of the following should be included
in your patient education?
A. Need for follow up OGTT
B. Increased risk for Type 2 DM
C. GDM likely in future pregnancies
D. All should be included

39. Institute for Healthcare Improvement. (2012).
Safe perinatal care: Reducing harm from
oxytocin and measuring improvement.
Retrieved from http://www.ihi.org/
offerings/Training/SafeOxytocin/Pages/defa
ult.aspx
Lowdermilk, D. L., Perry, S. E., & Cashion, K.
(2010). Maternity Nursing. (8th ed. ).
Maryland Heights, MO: Mosby.