Background
Client Information
Lena, a 22-year-old waitress, is admitted to the triage. She stays with her boyfriend, who also pays for her medication following back surgery that she underwent, having survived a car accident.
She is a GP1 P0 Ab 0 whose expected date of confinement is not known because her menstrual cycle is irregular- she is unaware of the actual duration for which she has been pregnant. She has visited the facility for prenatal care, but not on a regular basis. She is 5 feet 5 inches tall, weighed 125 pounds at her first prenatal visit, but has since gained weight and currently weighs 150 pounds. Her hemoglobin level at present admission is at 9.9 mmol/L. She has a hematocrit of 34 % and ascribes to blood group A+. Lena has no history of narcotic abuse. She has, however, lived on Percocet as pain relievers for two years following a back surgery after the car accident. She has been using the drug without any safety precautions throughout her pregnancy. She tested negative for HIV, Hepatitis A, Hepatitis B, and is immune to Rubella and Varicella.
At admission, she presented complaints of contraction pains and is incessantly requesting for analgesics. Her cervical examination reveals that she is dilated by 2 cm and leaks a light meconium-stained fluid. She is then admitted to labor and delivery, from where an intravenous administration of Lactated Ringer’s solution is started at 125ml/hour. She is then subjected to intrapartum antibiotic prophylaxis. For the prophylaxis, she was treated with a 5-million –union infusion of penicillin G, followed by a 2.5 million IV over 30 minutes every four hours until she delivered. Her urine samples tested positive for opiates. She was then treated to an epidural to ease the pain. She was also given the Nubain to precipitate the withdrawal syndromes of opiates that were confirmed by the urine test. The laboratory results after the epidural point to a category I tracing with an FHT baseline of 155, with moderate variability and occasional accelerations up to 170 that last for 40 sec. There is occasional variable deceleration, and the contractions occur for 60 seconds for every 5minutes. The spontaneous repute of the membrane let out the light green amniotic fluid. The cervix is dilated at 4 cm. After two hours, the FHT rises to a baseline of 165 with minimal variability and recurrent late decelerations. The contractions become frequent, taking place every 2-3 minutes and lasting for about 60 seconds. The cervical dilation at this moment is at 5 cm. She is taken in for cesarean delivery.
Assessment
Postpartum/Newborn
Lena underwent a successful caesarian delivery and delivered a healthy baby girl. After birth, she continued complaining about pain. In remedy, she was given Duramorph through her epidural catheter. From her reaction, the severity of the pain reduced significantly. She expressed the desire to breastfeed her baby. From the results of her first post-partum assessment, Lena’s temperature was at 370C; her pulse was at 100 and respiration 20. She had an oxygen saturation of 99%, and all her incisions were clean, dry, and intact. She was active and showed signs of rapid recuperation from childbirth. She did not show signs of mental unrest and took compliments composedly. Upon minor interrogations, she admitted to her anxiety to take care of the baby. She also confessed to feeling restless. She had not experienced any bowel complications and reportedly had a loose stool. She had a slight tremor on her hands, which is normal after childbirth. She also showed signs of fatigue, evidenced by yawning at two different instances during the assessment. Although she appeared to be physically stable, she complained of mild arthralgia and myalgia. She was anxious about developing a cold, her suspicions resting on the fact that her nose was stuffy. The newborn registered Apgar score of 7 at 1 minute and nine at 5 minutes after birth. She weighed 2409.7 g and had a length of 48.3 cm. This is a low birth weight. Her temperature was optimal at 36.5o C, and the respiration rate of 62 was slightly beyond the normal range. She had a loose, watery stool and had nasal stuffiness. She sneezed several times and was very irritable to the point of crying when being handled.
Priority Lab Tests and Implications for Clients
| Client | Test Value | Implication |
| HR 100 | Heart rate is high | |
| RR 20 | Respiratory rate is optimal. | |
| Temp 37oC | Temperature is optimal | |
| Hg 9.9 mmol/L | The hemoglobin level is normal. | |
| SpO2 99% | Oxygen saturation is optimal. | |
| Rhesus positive | No risk of erythroblastosis fetalis | |
| Rubella immune | No risk of miscarriage Newborn not at risk of severe birth defects. | |
| Varicella immune | Newborn not at risk of varicella | |
| Hepatitis A and B negative | Newborn not at risk of contracting hepatitis. | |
| Group B strep status unknown | No established indication for intrapartum prophylaxis. Increased risk of neonatal GBS infection (Ward & Hisley, (2015). | |
| Infant | Temp 36.5o C | Temperature is optimal |
| RR 62 | Respiratory Rate is slightly high |
Medication
| Drug | Duramorph | Penicillin | Morphine | Vitamin K |
| Recipient | Mother | Mother | Infant | Infant |
| Pregnancy Classification | Category C(in all the trimesters) | Category B | N/A | N/A |
| Safety in Lactation | Safe | Partially Safe, the drug may appear in breast milk. Introduce infant to penicillin | N/A | N/A |
| Purpose | Reduce severe pain | Prevent the development of GBS in the infant | Reduce the withdrawal symptoms | Preventing vitamin K deficiency bleeding (VKDB) |
| Action | Stimulates opioid receptors in the CNS to produce respiratory depression. | Bactericidal. Inhibits bacterial wall synthesis. | Stimulates opioid receptors in the CNS to produce respiratory depression. | Formation of active clotting factors II, VII, IX, and X. |
| Dose | A single injection 0.2 to 1 mg every 24 hours | 5 million units followed by 2.5 IV over 30 minutes every 4 hours during labor | 0.05 mg/kg/dose If scores are 12 or higher two consecutive times, increase the dose to 1.3 mg/kg/day Add clonidine if maximum dose reached | 1 mg/M in the first hour of birth |
| Route | Injection | Injection | infusion | a single IM injection |
| Side Effects | · Hypotension · Urinary retention · Gastrointestinal disturbances · dependence | · Dizziness · Fatigue · Nausea · Nephropathy · Hypersensitivity reaction | · Hypotension · Urinary retention · Gastrointestinal disturbances · dependence | Mild hypersensitivity reactions |
Plan
Priority Nursing Diagnosis
Maternal opioid dependence. The extensive use of opioids during pregnancy leads to poor pregnancy outcomes for both the mother and the infant (Cleveland, 2016). Majorly, the complications of opioid use during the gestation period is usually short-lived, with Neonatal Abstinence Syndrome (NAS) as the predominant complication. NAS references a set of drug withdrawal symptoms whose clinical presentation is dependent on the type of opioid that has been used. For the case of the mother, the symptoms such as yawning, anxiety, myalgia and arthralgia, restlessness, and slight tremors were indications that she could be experiencing withdrawal symptoms associated with the extensive use of the prescribed Percocet.
Prenatal exposure to opioids. An infant born to an opioid-dependent mother risks experiencing NAS due to the prenatal exposure to opioids. The symptoms of opioid withdrawal commence shortly after birth. These symptoms are at a peak within the first 72 hours post-delivery and decrease thereafter, but some extend to several weeks up to 30 days (Lacaze-Masmonteil & O’Flaherty, 2018). Some of the symptoms displayed by the baby, including irritability, yawning, sneezing, and sleep disorders, among others, indicate an apparent Utero exposure to Percocet.
Planning
Part of the intervention for the mother is putting her on an opioid maintenance therapy program. As a recommendation, the mother should be put on methadone or buprenorphine as an alternative treatment. Such an opioid substitution therapy may reduce opioid dependence, in turn, improving postnatal care. Other intervention strategies should entail access to education, counseling, and family support. Together, the opioid maintenance therapy would be and a combination of comprehensive medication and social support- an approach that is recommended by Lacaze-Masmonteil and O’Flaherty (2018).
Managing the infant who has been exposed to opioids during pregnancy should be focused on preventing the complications relating to NAS. This should also entail the restoration of the newborn’s normal activities such as sleep, weight gain, enough sleep, and the ability to adapt to the environment.
All relevant interventions
Capabilities and limitations
The initial intervention of neonatal withdrawal is attainable because the treatment relies majorly on available pharmacological and nonpharmacological interventions. Particularly, the non-pharmacological interventions have been proved to be effective in reducing the withdrawal symptoms, especially when implemented within the shortest time possible after birth. Some of these interventions require supportive environments that can be achieved within the hospital setting. Examples include providing quiet environments, minimal stimulation, lowering the lighting, gentle waking, skin-to-skin contact, appropriate developmental positioning, and massage therapy (Lacaze-Masmonteil & O’Flaherty, 2018). The biggest limitation to the goal of this therapy for the mother arises because of the pharmacological interventions. There is a risk that medications can prolong hospitalization, create disruptions in the mother-infant attachments, and also subject the infant to unnecessary medication.
The goal of reducing the impacts of prenatal exposure to opioids in the newborn is possible as long as the mother is effectively involved in opioid maintenance therapy. The mother is HIV–negative, stable, and on appropriate opioid maintenance therapy. This makes it possible for the mother to breastfeed the infant (Lacaze-Masmonteil & O’Flaherty, 2018). Through breastfeeding, the child gets exposed to optimal nutrition, maternal-infant attachment, and competent parenting. Breastfeeding also delays the start and reduces the acuteness of the withdrawal symptoms for the baby, hence the need for pharmacological interventions.
Nursing interventions.
There are several medications for lessening neonatal opioids withdrawal symptoms. Two of the most common frontline pharmacological agents in this category are morphine and methadone (Lacaze-Masmonteil & O’Flaherty, 2018). For the infant, the use of sublingual buprenorphine in place of oral morphine is proven to be highly effective in reducing the duration of hospital stays.
Evaluation.
The goal of lessening the impact of opioid withdrawal will first be evaluated after the first 72 hours of childbirth. The threshold treatment should be reached over that period; otherwise, the child remains illegible for discharge. To successfully contain the condition, there is the need to ensure that an interprofessional team plans the continuity of care even after the infant and the mother transitions to home.
Reflection
I have noted that the relationship between a mother and the inborn is delicate. There is more to pregnancy than gestation. Accordingly, every decision a mother makes is determinant of her overall wellbeing and that of the baby she carries. If Lena had paid serious attention to prenatal care, she would have been introduced much earlier to the opioid maintenance therapies and would not have placed the baby at the risk of NAS. From this, I would advise future mothers to pay attention to their health during pregnancy as much it is vital to the unborn as much as it is to the mother.
References
Cleveland, L. M. (2016). Breastfeeding recommendations for women who receive medication-assisted treatment for opioid use disorders: AWHONN Practice Brief Number 4. Nursing for women’s health, 20(4), 432-434.
Lacaze-Masmonteil, T., & O’Flaherty, P. (2018). Managing infants born to mothers who have used opioids during pregnancy. Paediatrics & child health, 23(3), 220-226.
Ward, S., & Hisley, S. (2015). Maternal-child nursing care optimizing outcomes for mothers, children, & families. FA Davis.