IDENTIFICATION DATA OF THE PATIENT:

Name Gurpreet kaur W/O Tajinderpal Singh

Age 32 years
Sex Female
LMP 8-6-2016
EDOD 15-3-2015
POG 36 weeks 2 days
GPAL G2P2L1A0
Marital status Married
Religion Sikh
Educational status 6th
Occupation Housewife
Address Dhotian , Amritsar
Date of admission 13-3- 2017
Date of delivery 14-3-2017
Time of delivery 4:00pm
Diagnosis IUD
Type of delivery Normal vaginal delivery
Sex of baby Male
Doctor in charge Dr. Guljit kaur
CHIEF COMPLAINTS:

Patient came to the SGRD Hospital vallah Amritsar on 13 March 2017 at 3:00 pm with the
following complaints.

No fetal movements

Retrogression of abdomen

PRESENT HISTORY:

Patient has history of amenorrhea from last 36 weeks 2 days, No fetal movements from last 3
days, Retrogression of abdomen therefore husband Mr. Tajinderpal Singh bring her in SGRD
Hospital vallah Amritsar for getting treatment. Doctor advised the patient for ultrasonography.
Ultrasound report shows baby was dead from 24 weeks of gestation. She is diagnosed with
intrauterine fetal death.

PRESENT SURGICAL HISTORY

Patient having no surgical (LSCS) history.

PRESENT MEDICAL HISTORY

Patient having no medical history.

PAST HISTORY

 MEDICAL : Patient has not any significant past medical history.

 SURGICAL: Patient has not any significant past surgical history.

FAMILY HISTORY
MATERNAL MEDICAL HISTORY

Mother No Any Medical History

Father No Any Medical History

PATERNAL MEDICAL HISTORY

Mother No Any Medical History

Father No Any Medical History

FAMILY TREE

Patient Husband

32 Yrs 35 Yrs

6th 10th

Housewife Shopkeeper

Daughter 5 yrs, student

OBSTETRICAL HISTORY:
Married Since 2007

Obstetrical Score G2P2L1A0

Sr.no Year Pregnancy Method of Sex of baby Baby status

event delivery
1 2012 Uneventful NVD with Female Normal
episiotomy
2 2017 Uneventful NVD Male IUD

a) Past obstetrical history:

Patient had not significant past obstetrical history

b) Present obstetrical history:

First trimester: No any history of nausea, vomiting, vaginal bleeding etc.

Second trimester:

 No swelling of extremities and face.

 No signs of vaginal or urinary infection
 No visual disturbances.
 Not taking any type of drug.
 No vaginal discharge

Third trimester

 No fetal movements
 Retrogression of abdomen
 No fetal heart rate

MENSTRUAL HISTORY

 Age of Menarche 14 years

 Flow Normal
 Duration 3-5 days
 Dysmenorrhea Absent
  Cycle 28 days

PERSONAL HISTORY: Patient is conscious and cooperative. Patient is neat and clean and
well oriented to her surroundings. Patient used condom for contraception.

Personal Habits: Habits of drinking water early in the morning, maintain personal
hygiene, Watching T.V, cooked food in hygienic conditions.
Dietary Habits: Vegetarian and taken meals 3 times a day. Patient takes light,
nutritious, easily digestible diet and which is rich in protein, minerals and vitamins.
Doctor prescribed one iron tablet i.e. 45 mg as supplementary nutritional therapy but
never taken.
Sleeping Pattern: Normal, 2 hour in afternoon and 8 hours in night.

SOCIO-ECONOMIC DATA:
 Total number of family members: 3
 Number of earning members in the family: 1
 Monthly income: Rs. 8000/month
 Housing conditions: Pucca house, proper water supply, hygiene conditions maintain by
cleanliness and proper drainage system.

GENERAL PHYSICAL ASSESSMENT:

Patient is a 32 years old female, with pulse rate of 80 beats per minute, respiratory rate of 20/
minute and a temperature of 37⁰C. She is conscious and maintains interaction with others. She is
comfortable and gives response to each question.

PHYSICAL EXAMINATION

General appearance:

Nourishment: Malnourished

Body build: Patient looks good

Health: healthy
Activity: Dull

Anthropometric measurements

 Height:164 cm
 Weight: 75 kg

Mental status Conscious

Head

 Hair Equally distributed and black in color

 Scalp Dandruff is not seen

Eyes

 Eye brows Symmetrical

 Conjunctiva Normal
 Eye Lids No Infection
 Vision Normal
 Sclera Normal

Nose

 Nasal Discharge: No any abnormal discharge

 Nostrils are moist
 Epistaxis Absent

Mouth

 Gums No swelling
 Lips Black
 Teeth
Alignment Symmetrical
 Color Yellowish
 Dental caries absent
  Tongue Coated

Ear

 Alignment Symmetrical
 External ear: normal, no any discharge
 Tympanic membrane: Normal with no perforation
 Hearing: Normal
 Ears are clean, no ear wax was noted and both ears are in same size and shape. Patient
can hear normally.

Neck

 ROM Normal
 Thyroid Gland: No enlargement, no neck rigidity.
 ROM Normal

Breast Enlarged due to pregnancy

 Shape Round
 Areola Dark in color
 Nipples: secretory discharge present
 Absence of lesions

Upper extremities:

Normal range of motion.

Edema is not present.

Nails

 Shape Flat
 Color Yellow
 Thickness Uniform
Abdomen

Inspection : Striae Gravidarum and linea Nigra seen , no any previous scar.

Palpation: fundal height is 14 cm

Genitalia :

Lochia rubra is present

Bladder habits are regular

No swelling on vulva

Rectum

 Absence of redness & hemorrhoid

 Patient is having constipation.
INVESTIGATION DATE WISE

Date Investigations Patient Value Normal Value Remarks

3.3.15 PCR +ve +ve -

“ HBsAg _ve _ve -

“ HCV _ve _ve -

“ HIV _ve _ve -

“ VDRL _ve _ve -

“ Hb 12 gm 12-14gm Normal

“ TLC 9800 5000-10000 Normal

“ ESR 20 0-20 Normal

Blood group A +Ve ---------- ------------

SPECIAL INVESTIGATION:

 ULTRASOUND :
Ultrasound report shows baby was dead from 24 weeks of gestation.
VITAL SIGNS

S.no DATE VITAL PATIENT NORMAL REMARKS

SIGNS VALUE VALUE

1 3.3.15 Temp. 98o F 98.6o F Normal

Pulse 80 /min. 72-80/ min Normal

B.P 110/70mm of Hg 120/80mm of Hg Mild Decreased

Respiration 20/ min 16-24/ min Normal

2 4.3.15 Temp. 98o F 98.6o F Normal

Pulse 90 / min 72-80/ min Mild increased

B.P 110/60mmofHg 120/80mm of Hg Mild Decreased

Respiration 24/ min 16-24/ min Normal

3 5.3.15 Temp. 99o F 98.6o F Slightly Increased

Pulse 84 / min 72-80/ min Slightly Increased

B.P 110/70mmofHg 120/80mm of Hg Slightly decreased

Respiration 24/ min 16-24/ min Normal

MEDICATION

SR.NO NAME OF DRUG DOSE ROUTE FREQUENCY ACTION

.
1. Inj .aciloc 25mg I/V BD Antacid
2. Inj. Tramadol 50mg I/M BD Analgesic
3. Inj. Ceftriaxone 1 gm I/V BD Antibiotic
4. Cap. Amoxicillin 250 mg P/O BD Antibiotic
5. Tab. Cabolin 2.5 mg P/O BD To suppress the
production of milk
CASE IN DETAIL

ANATOMY AND PHYSIOLOGY OF UTERUS

The Uterus is the organ of pregnancy as this is where implantation and development of the feotus
occurs. The Uterus is the reproductive organ with the most species variations. These variations
occur in both the anatomical types of uterus as well as the uterine horn appearance and
endometrial linings.

LOCATION OF THE UTERUS

The uterus sits centrally in the pelvis supported by strong fibrous structures called ligaments

FEMALE REPRODUCTIVE SYSTEM

The uterine muscle wall expands greatly during pregnancy and strong contractions of this muscle
wall during childbirth give rise to the pains of labour. You experience similar contractions on a
much smaller scale during menstruation, and this is the cause of the period pain (dysmenorrhoea)
which troubles so many women.
STRUCTURE
The uterus, or womb, is shaped like an inverted pear. It is a hollow, muscular organ with thick
walls, and it has a glandular lining called the endometrium. In an adult the uterus is 7.5 cm (3
inches) long, 5 cm (2 inches) in width, and 2.5 cm (1 inch) thick, but it enlarges to four to five
times this size in pregnancy. The narrower, lower end is called the cervix; this projects into
the vagina. The cervix is made of fibrous connective tissue and is of a firmer consistency than
the body of the uterus. The two fallopian tubesenter the uterus at opposite sides, near its top. The
part of the uterus above the entrances of the tubes is called the fundus; the part below is termed
the body. The body narrows toward the cervix, and a slight external constriction marks the
juncture between the body and the cervix.

The uterus does not lie in line with the vagina but is usually turned forward (anteverted) to form
approximately a right angle with it. The position of the uterus is affected by the amount of
distension in the urinary bladder and in the rectum. Enlargement of the uterus
in pregnancy causes it to rise up into the abdominal cavity, so that there is closer alignment with
the vagina. The nonpregnant uterus also curves gently forward; it is said to be anteflexed. The
uterus is supported and held in position by the other pelvic organs, by the muscular floor or
diaphragm of the pelvis, by certain fibrous ligaments, and by folds of peritoneum. Among the
supporting ligaments are two double-layered broad ligaments, each of which contains a fallopian
tube along its upper free border and a round ligament, corresponding to the gubernaculum testis
of the male, between its layers.

The uterus is composed of three layers of tissue

PERIMETRIUM
On the outside is a serous coat of peritoneum (a membrane exuding a fluid like blood minus its
cells and the clotting factor fibrinogen), which partially covers the organ. In front it covers only
the body of the cervix; behind it covers the body and the part of the cervix that is above the
vagina and is prolonged onto the posterior vaginal wall; from there it is folded back to the
rectum. At the side the peritoneal layers stretch from the margin of the uterus to each side wall of
the pelvis, forming the two broad ligaments of the uterus.
MYOMETRIUM
The middle layer of tissue (myometrium) is muscular and comprises the greater part of the bulk
of the organ. It is very firm and consists of densely packed, unstriped, smooth muscle fibres.
Blood vessels, lymph vessels, and nerves are also present. The muscle is more or less arranged in
three layers of fibres running in different directions. The outermost fibres are arranged
longitudinally. Those of the middle layer run in all directions without any orderly arrangement;
this layer is the thickest. The innermost fibres are longitudinal and circular in their arrangement.

ENDOMETRIUM
The innermost layer of tissue in the uterus is the mucous membrane, or endometrium. It lines the
uterine cavity as far as the isthmus of the uterus, where it becomes continuous with the lining of
the cervical canal. The endometrium contains numerous uterine glands that open into the uterine
cavity and are embedded in the cellular framework or stroma of the endometrium. Numerous
blood vessels and lymphatic spaces are also present. The appearances of the endometrium vary
considerably at the different stages in reproductive life. It begins to reach full development
at puberty and thereafter exhibits dramatic changes during each menstrual cycle. It undergoes
further changes before, during, and after pregnancy, during the menopause, and in old age. These
changes are for the most part hormonally induced and controlled by the activity of the ovaries.
CERVIX

The cervix can be palpated transrectally and forms a sphincter controlling access to
the uterus.The anatomy of the cervical canal is adapted to suit a particular pattern of reproduction
and its composition will alter under the influence of reproductive hormones. Not only does it
respond to the fluctuation in oestrodiol during the oestrous cycle, but is responsive to
prostaglandins and oxytocin in order to 'soften' for parturition.
STRUCTURE

 The lumen of the cervix is the cervical canal.

 The canal is formed by, and often almost occluded by mucosal folds.
 Single fold and smooth surface in the queen and bitch
 Multiple folds protruding into the cervical canal in the cow, ewe, sow and mare.
 The cervical canal opens cranially into the body of the uterus at the internal
uterine ostium.
 The cervical canal opens caudally into the vagina at the external uterine ostium.
In the nonpregnant state, the cervix comprises the lower one-third of the uterus and connects the
uterine cavity to the vagina. The overall length of the cervix is highly variable but generally falls
in the range of 2.5 to 5.0 cm. Only about one-half to one-third of the cervix extends into the
vagina and this is called the portio vaginalis. The portion of the cervix that opens into the vagina
is called the external cervical os; the uppermost portion that opens into the uterus is called
the internal cervical os. As we will emphasize in later discussion, the internal cervical os is a key
player in the etiology, pathogenesis, and diagnosis of cervical incompetence. The portion of the
cervix that connects the external os and internal os contains the endocervical canaland this
narrow tube separates the relatively unsterile environment of the vagina from the uterine cavity.
The endocervical canal is lined by a single layer of mucous producing cells and the chemicals
and immunoglobulins that are secreted into the canal provide the major barrier to ascending
infection by potential pathogenic microorganisms from the vagina and ectocervix.

Although the cervix is contiguous with the body of the uterus, it is structurally different from the
uterus in several key aspects. Both the uterine wall (the myometrium) and the cervix contain
smooth muscle and fibrous connective tissue, but there is a much greater percentage of the
connective tissue in the cervix than in the myometrium. The uterus is “designed” to contract and,
when the time is right, eventually push the baby out, while the role of the cervix, under normal
circumstances, is to keep the baby inside until it is mature enough to survive in the cold cruel
worldoutsidethewomb.
The fibrous connective tissue of the cervix is mostly composed of types I and II collagen, elastin,
and proteoglycans. The collagen is heavily ‘cross-linked’ and this imbues the cervix with a
tremendous resistance, again under normal circumstances, to stretching and ‘softening’ until the
biochemical cascade that progresses to labor ensues. At that point, the cervix is capable of
undergoing a remarkably rapid transformation from a structure that has the consistency of a
rubber eraser to the soft, compliant, elastic structure that will permit the relatively easy passage
of the baby from the uterus and into the birth canal – a transformation that results from the
remodeling (uncross-linking) of the collagen and the extracellular matrix. 

FEMALE REPRODUCTIVE SYSTEM

CASE IN DETAIL (INTRAUTERINE DEATH)

When a fetus that was expected to survive dies during birth or during the last half of pregnancy,
it is known as intrauterine death. Once the fetus has died the mother still has compressions and
the remains are delivered. The term is often used in distinction to live birth or miscarriage. Most
intrauterine death happen in full term pregnancies.

Antepartum death occurring beyond 28wk is termed as I.U.D. and it usually results in the
delivery of a macerated fetus.

ETIOLOGY

IN BOOK IN PATIENT
Maternal pathology includes :
 Prolonged pregnancy (>41 weeks) Absent
 Diabetes Absent

 Systemic lupus erythematosus Absent

 Antiphospholipid syndrome Absent

Absent
 Infection
Absent
 Hypertension
Absent
 Preeclampsia
Absent
 Eclampsia
Absent
 Hemoglobinopathy
Absent
 Advanced maternal age
Absent
 Rh disease
Absent
 Uterine rupture Absent
 Maternal trauma or death Absent
 Inherited thrombophilias
Fetal pathology includes Absent
  Multiple gestations Present
 Intrauterine growth restriction Absent

 Congenital abnormality Absent

 Genetic abnormality Present

 Infection

Absent
Placental pathology involves
Absent
 Cord accident
Absent
 Abruption
Present
 Premature rupture of membranes Present
 Fetomaternal hemorrhage
 Placental insufficiency

SYMPTOMS:

IN BOOK IN PATIENT
 A mother who notices the baby has Present from last 3 days
stopped moving for a long period of time
 A uterus or womb that fails to get Present

bigger over time

Present
 An inability to hear the baby's heartbeat
with a special heart monitor
 Lack of movement of the baby or no
Present
heartbeat during a pregnancy ultrasound
 An abnormal blood level of the
Absent
hormone of pregnancy
DIAGNOSTIC FINDINGS

IN BOOK IN PATIENT
1. Sonography Ultrasonography is done. Report shows baby
was dead from 24 weeks of gestation.

2. Straight X-ray abdomen

 Spalding sign: The irregular Spalding sign was present. Cranial bones
overlapping of the cranial bones on overlapping to one another.
one another. It appears 7 days after
death.
 Hyperflexion of the spine is more
common
 There is crowing of ribs shadow with
loss of normal parallel.

3. Estimation of blood fibrinogen level

and partial thromboplastin time. Not done

4. Hematological examination includes:

 ABO &Rh grouping Not done
 BUN
 Thyroid profile
 TORCH
 Lupus anticoagulant and anticardiolipin
antibodies.
MANAGEMENT:

IN BOOK IN PATIENT

Curative treatment Not given to the patient.

a. When pregnancy is near term expectant
treatment is followed 4weeks.
b. Expulsion away occurs by the time
term pregnancy is reached.
c. Patient and her relatives are properly
assured of her safety by non
interference for 4weeks.
d. Check the blood coagulation profiles.

Active treatment
 Early intrauterine death may be
Not done
managed with laminaria insertion
followed by dilatation and evacuation.
 In women with intrauterine death
Oxytocin 5 IU dilute in 500 ml RL I/V given to
before 28 weeks' gestation, induction
the patient to induce labour pains.
may be carried out using prostaglandin
E2 vaginal suppositories (10-20 mg q4-
6h), misoprostol (ie,prostaglandin E1)
vaginally or orally (400 mcg q4-6h),
and/or oxytocin. In women with
intrauterine death after 28 weeks'
gestation, lower dose used.

 In women with no uterine scar, Misoprostol 25 mg tab given to the patient

 misoprostol (25 mcg q4-6h) may be
dispensed for ripening after 28 weeks’
gestation. For women with a prior
cesarean delivery, mechanical ripening
can be carried out with a Foley catheter,
and induction can be continued with
oxytocin.

NURSING ASSESSMENT

 Take a complete history of the patient.

 Assess the patient for anxiety due to loss of the baby.
 Check the breast of the patient for secretions and note breast engorgement problem.
 Check the vaginal bleeding of the patient to note the colour of lochia.

NURSING DIAGNOSIS:

1. Anticipatory grieving related to an unexpected pregnancy outcome

2. Risk for infection related to intrauterine death from last 24 weeks of gestation.
3. Imbalanced nutrition: less than body requirement related to inadequate dietary intake .

SHORT TERM GOALS:

1. To resolve the grief.

2. To reduce infection
3. To improve the nutritional status

LONG TERM GOALS: After months of nursing interventions, the patient:

 To reduce the risk for complications.

 To reduce anxiety
 NURSING CARE PLAN

Sr No.
1.
HEALTH EDUCATION

 Taught the mother to eat roughage diet and drink plenty of fluid to prevent constipation.
 Taught the mother to report the signs of infection i.e increase temperature and sign of
haemorrhage i.e heavy bleeding per vagina.
 Provide psychological support to the mother.
 Give cabolin Tab to the mother to suppress the production of milk.
 Taught the mother about the use of breast pump to expressed the milk from breast.
BIBLIOGRAPHY:

 Dutta DC. Textbook of Obstetrics. Edition sixth 2004, Published by New Centeral Book
agency (P) Ltd. 8/1 Chintamoni, Das Lane: Calcutta 700009 (India). Pp- 216 - 25.

 Kumari Neelam, Sharma Shivani, Dr. Gupta Preeti. Midwifery & Gynaecological
Nursing. Ed-Ist. Pee Vee (p) Ltd. Pp 284-6

 Sanju Sira. A Textbook of Midwifery and obstetrics. Ed- 2nd; Lotus Publishers, Pp- 206
-13.

 Lippincott Williams and Wilkins. Lippincott Mannual of Nursing Practice. Ed- 8 th,
published by- Jaypee brothers, Pp- 1270 -75.
 SGRD COLLEGE OF NURSING , VALLAH
AMRITSAR
SUBJECT: obstetrics and gynaecological nursing
Case study
On
Intrauterine death

SUBMITTED TO : submitted by:

RESP. Dr. karuna sharma gurinderpal kaur
professor m.sc (n) iind year
OBSTETRICS AND GYNAECOLOGICAL (obg)
NURSING
Submitted on 18/3/2017