TABLE OF CONTENTS

I. Introduction
II. Objectives
III.Anatomy and Physiology
IV. Psychosocial Profile
a. Demographic Data
b. Genogram
c. Growth and development
V. Pathophysiology
VI. Physical Assessment
a. Medical Management
b. Laboratory Results
c. Pharmacology
VII. Functional Health Patten
VIII. Nursing Care Plans
IX. Related Readings

I. Introduction
 Stillbirth is the birth of a baby who is born without any signs of life at or after 24 weeks pregnancy. The
baby may have died during pregnancy (called intrauterine death), labor or birth. WHO defines stillbirth
with a birth weight of at least 1000g or a gestational age of at least 28 weeks (third-trimester stillbirth).
The loss of a fetus at any stage is a fetal demise. According to the 2003 revision of the Procedures for
Coding Cause of Fetal Death under ICD-10, the National Center for Health Statistics defines fetal death as
"death prior to the complete expulsion or extraction from its mother of a product of human conception,
irrespective of the duration of pregnancy and which not an induced termination of pregnancy is. The death
is indicated by the fact that after such expulsion or extraction, the fetus does not breathe or show any
other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement
of voluntary muscles. Heartbeats are to be distinguished from transient cardiac contractions; respirations
are to be distinguished from fleeting respiratory efforts or gasps." A death that occurs prior to 20 weeks'
gestation is usually classified as a spontaneous abortion; those occurring after 20 weeks constitute a fetal
demise or stillbirth. Many states use a fetal weight of 350 g or more to define a fetal demise.
There is currently, as of 2016, no international classification system for stillbirth causes. The causes of a
large percentage of human stillbirths remain unknown, even in cases where extensive testing and autopsy
have been performed. Some possible causes are: 1. Women who suffer from pre - eclampsia also increase
the risk of placental abruption by 50%. Women who have experienced a stillbirth in a previous pregnancy
should receive careful, regular prenatal care to ensure another stillbirth does not occur. 2. Risk factors for
stillbirth that can be identified before a woman becomes pregnant, having a prior stillborn baby, having
prior miscarriages and not having other children were all associated with added risk. 3. Women with
diabetes had 2.5 times the risk of stillbirth and women aged 40 and older had 2.4 times the risk of stillbirth
as women aged 20 to 34. 4. Having an AB blood type, smoking in the three months before pregnancy,
overweight/obesity and a history of drug addiction were also associated with higher risks. One of the
common reasons for stillbirths is placental abruption. This is when the placenta begins to strip away from the uterine
wall causing heavy bleeding and deprivation of oxygen to the fetus. Chromosomal abnormalities are another
cause of stillbirths. While they are the most common factor for miscarriages in the first trimester, a
miscarriage due to a chromosomal abnormality can occur at any time during a pregnancy. Other causes of
stillbirth include gestational growth problems, environmental factors, genetic defects, and bacterial
infections (such as listeriosis) in the mother. Additionally, the risk of a stillbirth increases with the maternal
age.
The mother may notice less movement in the fetus for several days, and her breasts may diminish in
size. In cases of hypertension the blood pressure sometimes falls. The following signs may be found: After
the 24th week the fetal heart sounds can normally be heard with a stethoscope; failure to hear them will
be strong presumptive evidence of fetal death. An ultrasound scan can detect the fetal heart beat as early
as the 8th week of pregnancy, and if a careful and repeated search shows no evidence of cardiac activity,
fetal death is almost certain. The uterus may be found to be smaller than the duration of pregnancy would
warrant. A more accurate sign is to note how much the uterus grows during a period of observation. For
this the bladder must be empty and the level of the fundus accurately noted during an ultrasound. The
patient is examined week by week. If no uterine enlargement is observed in 4 weeks this strongly suggests
that the fetus is dead. In some cases the uterus not only ceases to grow but gets smaller because of
absorption of the amniotic fluid. Sometimes secretion of colostrum (pre-breast milk) from the breasts
occurs a few days after the death of the fetus. Ultrasonic examination will show overlapping and
misalignment of the skull bones (Spalding's sign) and occasionally the presence of gas in the fetal heart
and blood vessels (Roberts' sign). Spalding's sign is not usually present until a week after fetal death, but
gas formation may be seen after only 2 days. Blood tests for pregnancy are usually negative within a week
after the death of the fetus, but sometimes a weakly positive test persists for a time, presumably because
some placenta tissue is still active. The excretion of estriol (a type of estrogen produced by an active
placenta) in the mother's urine falls sharply. As you can see, it is often difficult to diagnose fetal death from
a single clinical examination of the patient, and urgent regular sonography is usually requested. Doctors
tend not to place too much importance on the mothers statements about fetal movements as it may be
wishful thinking.
 II. Objectives
Nurse-centered Objectives:

After the completion of this case study for 2 days, I will be able to:

1.Determine major causes of Intrauterine Fetal Death.

2.Enumerate the predisposing and precipitating factors that
contribute to Intrauterine Fetal Death.
3.Perform comprehensive assessment to the clientele
cephalocaudally.
4.Identify the apparent signs and symptoms of the clientele in
relation to Intrauterine Fetal Death.
5.Decisively analyze the different laboratory and diagnostic
procedures and relate the results to the condition
6.State and identify the appropriate nursing diagnosis and make
essential interventions.
7. Provide suitable health teachings to promote awareness,
empowerment and wellness to the clientele.

III. Anatomy and Physiology

I. Female Reproductive System
a. External structures
1. Mons Veneris a pad of adipose tissue located over the symphysis pubis
2. Labia Minora two hairless folds of connective tissue
3. Labia Majora serves as protection for the external genitalia and distal urethra and vagina
b. Internal structures
1. Ovaries produces, matures and discharges ova (the egg cells)
2. Fallopian tubes conveys the ovum from the ovaries to the uterus and
site of fertilization.
3. Vagina serves as the birth canal and the receptacle for penis during
coitus
4. Cervix the opening where the fetus passes during childbirth
5. Ovaries the female gonads which secrete hormones and the ovum.
6. Uterus supports and nourishes the fetus during pregnancy; contracts to
aid childbirth; sheds during menstruation
 IV. Psychosocial Profile

a. Demographic Data
NAME: Patient X
AGE: 17 years old
GENDER: Female
DATE OF BIRTH: March 28, 2000
RELIGION: Catholic
CIVIL STATUS: Single
OCCUPATION: None
ADDRESS: P2 Muyo, Buug Zamboanga Sibugay
DATE ADMITTED: April 24, 2017
DR. IN CHARGE: Dr Cordenillo
DIAGNOSIS: Stillbirth

NURSING HISTORY

PRESENT MEDICAL HISTORY

Patient X reported uterine contractions which occurred at 11pm in the evening, April 26, 2017
within patients residence.Said that she had an increased urgency to urinate (it was the bag of
water already broken; patient mistook it for urine)

At 2 pm, patient decided to be brought to the BEMONC at once and I. E. was done. Midwife
checked for FHRT, but therewere no audible sounds. The midwives referred the mother to the
municipal health officer and ordered immediate transfer to a hopital. Hence, the patient refused
to do so and insisted to deliver at the BEMONC. Legalities were explained thoroughly. After 2hrs
the patient delivered a dead baby.

Obstetrical Hx:

G1 P0 T0 A0 L0
LMP = July 18, 2016
AOG = 38 weeks
Physical findings:

170/100 mmHg Preeclampsia

PAST MEDICAL HISTORY

Patient X reported that she had never been able to go the nearest health center to have her
prenatal visits said that she was busy and never had the time to do so
 Besides a slight pedal edema, patient has no known diseases during the course of her pregnancy
but she reported that her mother had a history of hypertension. Also, someone from the
immediate family has asthma.

Patient X is not a smoker and doesnt drink alcoholic beverages. Activities of daily living include
usual motherly household chores such a cooking, doing laundry works and being the all-around
homemaker. She admits that she is not active in ports but considers her household chores as her
daily exercise routine. Patient has usual diet of fish or pork, rice and vegetables.

b. Genogram
A.J.

50 Y.O

HPN

C.J. Patient X

30 Y.O 17 Y.O.

Legend:
Male Female

V. Pathophysiology

PATHOPHYSIOLOGY

Predisposing Factors: Precipitating Factors:

- Age: 27 y. o. - Late medical
- AOG: 34-35 weeks assistance
- Congenital anomalies - Preeclampsia of
mother

Edema

Premature labor as
manifested by uterine Preeclampsia
contraction
Elevated BP

Cord compression as a
result of
vasoconstriction
Premature rupture of
membranes (amnion)

Took a long time for Decreased blood flow

patient to be taken to and diminished O2
hospital transfer in placenta

Oligohydramnios

Intrauterine Fetal
Hypoxia

INTRAUTERINE FETAL
DEMISE

Induced labor

Stillbirth
 VI. Physical Assessment
INTEGUMENTARY
Skin
Light brown in color
Generally uniform, except in areas exposed to the sun
Absence of edema
Absence of abrasion, bruises, lesions
Moist in skin folds and in the axillae
Good skin turgor: when pinched, skin springs back to previous state within 2-4 seconds
Nails
Had clean fingernails and toenails with no clubbing on both hands and feet
Smooth texture
Nail bed has pale pigmentation with intact epidermis
Capillary refill test: prompt return of usual color for 3 seconds
Hair
Evenly distributed
Thick, greasy hair
No infection/infestation
With variable amount of body hair
HEAD
Skull and Face
Rounded (normocephalic and symmetrical, with frontal, parietal, and
occipital prominences)
Smooth skull contour
Absence of nodules, masses and edema
Symmetric facial features
Palpebral fissures equal in size
Presence of pimples

EYES
Eyebrows were symmetrically aligned with black hair evenly distributed
Eyelashes were black in color, equally distributed and curled slightly outward
Eyelids had intact skin with no discharges and discoloration
Palpebral conjunctiva was pale with no discharge
Pupils were brown in color, equal in size, round and with smooth border

EARS
Auricles has same color as the facial skin,
symmetrical, mobile, firm and not tender
Auricle aligned with outer canthus of eye
and pinna recoils after it is folded
Sticky, wet cerumen in various shades of
brown

NOSE AND SINUSES

 External nose was symmetric and
straight, with no lesions and are not tender
No discharge or flaring
Uniform color
Nasal septum intact and in midline
Nasal mucosa was pale

MOUTH AND THROAT

Lips are pale, soft but dry and symmetrical in contour
Buccal mucosa is pale pink in color , moist and smooth
Has 32 permanent teeth, 16 teeth in the upper jaw and in the lower jaw
Smooth, white to yellow in color, shiny tooth enamel
Pallor in gums, moist and firm in texture
Tounge is in central position, moist, slight pink in color and is slightly rough

NECK
Muscles equal in size
Lymph nodes are not palpable, not tender
Head centered
Trachea is in central placement in the midline of the neck and tracheal spaces are equal on both sides

RESPIRATORY/CHEST
Chest symmetrical in shape
Skin intact
Absence of lesions, tenderness, masses
Full and symmetric chest expansion
Quiet, rhythmic and effortless respirations
Absence of sputum and cough
 Absence of adventitious breath sounds

CARDIOVASCULAR/HEART
S1 heard at all times, louder at apical area
S2 heard at all times, louder at the base of the heart
Carotid arteries have symmetric pulse volume
Jugular veins are not visible
Peripheral pulses have symmetric pulse volume
Peripheral perfusion: skin color of the hands and feet are slightly pink, skin temperature is warm, no
edema seen
Capillary refill test: immediate return of color within 3 seconds

GASTROINTESTINAL/ABDOMEN
Abdominal incision with dry intact dressing present
There is a line of dark pigment on the abdomen (Linea Nigra)
Presence of red streaks on her abdomen (Striae Gravidarum)
Distended
No evidence of enlarged liver and spleen
there is tenderness upon palpation,

GENITO-URINARY
With tenderness upon palpation
With foley catheter draining to pinkish yellow urine @ 400 cc
With vaginal discharge (consumed 2 pads)

MUSCULOSKELETAL/EXTREMITIES
Equal size on both sides of the body
 No contractures, fasciculation or tremors
Normally firm and smooth
No deformities, tenderness nor swelling
Bones have no deformities, swellings or tenderness
Joints have no swellings, no tenderness, no nodules

a. Medical Management
April 27, 2017
2:00PM
Patient was admitted at BEMONC facility of Buug. Information were gathered through
structured interview. Vital signs were taken BP: 170/100 mmhg. IE done dilated 4-6cm. Absence of
fetal heart tone was noted. Patient was referred to Dr. Cordenillo with an order of referral to a
tertiary hospital carried out. Advised the patient and SO regarding the doctors order but the
parents and the patient refused. Thoroughly discussed patients condition and risk. Hence, patient
still refused to transfer. Secured consent for refusal and informed AP regarding the matter. Hooked
D5LR 1L @ 25 gtts/ min infusing via right metacarpal vein. Methyldopa and magnesium sulfate
given.
4:16 PM
Patient was in labor 10cm dilated and fully effaced.
4:52 PM
 Patient delivered a dead baby girl.
5:13 PM
Placenta out. Hooked with oxytocin 1 amp incorporated to present IVF.
April 28, 2017
Patient was still in grief and talks only minimally. BP is @ 110/70 mmhg. Continue medications
and VS are still monitored. On a SOFT diet.

b. Laboratory Results
Urinalysis (April 27, 2017)
Routine Urinalysis:
COLOR: Amber PUS: 25 30/ hpf
CHARACTER: Turbid RED BLOOD CELLS: 4 6/ hpf
SPECIFIC GRAVITY: 1.020 EPITHELIAL CELLS: Few
REACTION: Acidic BACTERIA: Few
SUGAR: - MUCUS THREADS: Few
ALBUMIN: + CRYSTALS: Amorphous urates; few
HEMOGLOBIN: 128 g/L
HEMATOCRIT: 0.41
RBC: ---
BLOOD TYPE: B positive

c. Pharmacology
NURSING
DRUG MECHANISM OF
INDICATION ADVERSE REACTION CONTRAINDICATION CONSIDERATIO
NAME ACTION
N

Generic Replaces and Mild/ severe Severe allergic Contraindicated in patients Checked
Name maintain magnesium hypomagnesemia reaction (rash; hives; with myocardial damage, mark magnesium
level; as . Magnesium itching; difficulty in myocardial disease, or heart level after
Magnesiu anticonvulsant, supplementation. breathing; tightness in block. IV form is repeated
m sulfate reduces muscle the chest; swelling of contraindicated in patients doses.
contraction by Hypomagnesemic the mouth, face lips or with preeclampsia during the
interfering with seizure. tongue); dizziness, 2 hrs preceding delivery. And Normal
Brand release of flushing; irregular to those patient with renal magnesium
Paroxysmal atrial level: 4-7
Name acetylcholine at heartbeat muscle impairment.
tachycardia in mg/dL
myoneural junction. paralysis; severe
Classificat patients Use magnesium sulfate
drowsiness;
ion Raises magnesium unresponsive to cautiously in patients with Monitor
levels, alleviates other therapies. impaired kidney function. patients fluid
Anti- seizures, and intake and
convulsan restores normal To manage pre output.
t term labor.
Be alert for
Dosage

Loading
dose: 4g
SIVP

And

5g Deep
IM

Route

SIVP sinus rhythm Severe acute adverse

asthma reaction.
And unresponsive to
conventional Watch out for
Deep IM signs of
therapy.
magnesium
Frequenc toxicity:
y
-urine output
Q6 <30cc/hr

-respiratory
rate <12-20cpm

ADVERSE
MECHANISM OF NURSING
DRUG NAME INDICATION CONTRAINDICATION
ACTION CONSIDERATION
REACTION

Generic Name Interferes with UTI, and disused for CNS: Chills, fever, Hypersensitivity to Use cefuroxime
bacterial cell wall surgical prophylaxis, headache, seizures cephalosporins or their cautiously in patients
Cefuroxime synthesis by reducing or
inhibiting the final eliminating infection. CV: Edema Components. hypersensitive to
Brand Name step in the penicillin because
It is effective for the EENT: Hearing loss, oral To patient who take crosssensitivity has
crosslinking of
Kefox treatment of candidiasis probenecid occurred in about 10% of
peptidoglycan
strands. penicilllinase such patients.
Classification GI: Abdominal cramps,
producing
diarrhea, elevated If possible, obtain
Peptidoglycan makes Neisseriagonorhoea
Antibiotic culture and sensitivity
the cell membrane (PPNG).
Dosage

500mg

Stock Dose

500mg (tablet)

Route

Oral

Frequency

BID

rigid and protective Effectively treats bone liver function test results, results, as ordered,
without it, bacterial and joint infections, hepatic failure, before giving drug.
cells rupture and die. bronchitis, meningitis,
gonorrhea, otitis media, hepatomegaly, nausea, Give oral form with food
pharyngitis/tonsillitis, pseudomembranous to decrease GI
sinusitis, lower
colitis, vomiting distress, as needed.
respiratory tract
infections, skin and soft GU: Elevated BUN level, Remember that oral
tissue infections. nephrotoxicity, formstablets and

renal failure, vaginal suspensionarent

candidiasis bioequivalent.

HEME: Eosinophilia, For I.V. use, reconstitute

hemolytic anemia, using manufacturers

hypoprothrombinemia, instructions according to

neutropenia, type of preparation
available. Solution ranges
thrombocytopenia, in color from light yellow
unusual bleeding to amber.
 ADVERSE
DRUG NAME MECHANISM OF ACTION INDICATION CONTRAINDICATION NURSING CONSIDERATION
REACTION

Generic Name Is decarboxylated in -To manage CNS: Decreased Active hepatic disease, Expect to monitor CBC and differential
the body to produce hypertension concentration, hypersensitivity to results before and periodically during
Methyldopa depression, methyldopa therapy.
alpha- -to treat methyldopa or its
methylnorepinephrine, hypertensive dizziness, components, impaired Monitor blood pressure regularly during
Brand Name a metabolite that drowsiness, fever, therapy.
stimulates central Crisis headache, hepatic function from
Amlodomet inhibitory previous methyldopa Monitor results of Coombs test; a
alphaadrenergic involuntary motor positive result after several months of
activity, memory therapy, use within 14 treatment indicates that patient has
Classification
receptors. This action loss days of MAO inhibitor. hemolytic anemia.
Antihypertensive may reduce blood
pressure by decreasing (transient), Expect to discontinue drug.
sympathetic nightmares,
paresthesia, Assess for weight gain and edema. If
Dosage stimulation of heart parkinsonism, they develop, give a diuretic, as
and peripheral prescribed.
500mg tab sedation, vertigo,
vascular system. weakness Notify prescriber if patient has signs of
Stock dose heart failure (dyspnea, edema,
CV: Angina, hypertension) or involuntary, rapid,
500mg (tablet) bradycardia, jerky movements.
edema, heart
Route Be aware that hypertension may return
failure,
within 48 hours after stopping drug.
Oral
Frequency

Q8

myocarditis,
orthostatic
hypotension.

VII. Functional Health Patten

Health Perception/ Health Management Pattern

Before admission, patient X does not really seek medical attention immediately they
often consult hilot or quack doctors for their healthcare needs due to their lack of financial
resources as verbalized by the patient. The patient does laundry for a living.

Nutritional-Metabolic Pattern

Patient verbalized that she usually eats vegetables that her family personally grows at
their residence. She also eats fish due to their geographic location which is near the sea thus, fish
is easily accessible to their area. Shes fond of dried fish. The patient drinks lots of water
everyday.

Elimination Pattern

Patient defecates once a day and have not encountered problems in urinary elimination
prior to admission. But during the times she was pregnant, the patient complained that she
always felt urinary urgency and frequency.

Activity/ Exercise Pattern

The patient verbalized that she always does exercise specially walking because she
walks frequently and does daily work chores which she considers as an exercise.

Cognitive / Perceptual Pattern

The patient verbalized that she matured early because she had to help her parents
financially. She said that she had to work early and leave school. She enjoys listening to the radio
during her free time and texting with her friends make her feel not alone.

Rest / Sleep Pattern

 Before admission, the patient will always have 8hrs of sleep a day she usually sleeps at
8PM and wakes up at 4am. She takes rest during noontime until around 2pm then goes back to
work after. During the admission, the patient frequently sleeps and cries when she awakes.

Self perception pattern

She views herself as a person who is responsible and she verbalized that she is
industrious and frugal in terms of money. She also said that in terms of work her employer had
never issues with her and thus considers her importance. She said that she is comfortable with
her body as it is.

Role Relationship Pattern

Prior and during admission the patient is very close to his mother, father and siblings. He
has good relationship with his siblings and so does to other people. She verbalized that she never
had any problems dealing with other people.

Coping Stress Tolerance Pattern

When she is stress at work or shes in a bad situation she usually talks to her friends and
neighbor. She also talks to the maid that shes working with. She also seek advise from her
parents and just tries to get on with life and think that she has to be strong for her parents.
Value Belief Pattern

The Patients values and beliefs is rooted as a Christian. She believed in GOD and always
attends Sunday masses. She also reads the bible when she has free time. now, she still verbalized
possibility even though she suffered grief. She said that her daughter is in a better place and
happy with god.

VIII. Nursing Care Plan

 Cues Diagnosis Scientific Reason Goal Intervention

Subjective: Mild anxiety For anxiety, women who have Short-term goal: Independent:
related to suffered adverse outcomes in
Ayoko na ulit outcome of previous pregnancies are at After 2 hours of Acknowledge Standard:
magbuntis, baka future particular risk. Miscarriage, nursing awareness of
mamatay lang yung intervention, patients anxiety. Patient should be
pregnancies fetal death, and preterm birth
ipinagbubuntis ko. patient will able to express
secondary to reduce womens quality of
appear calm, relax Rationale: feelings of anxiety
poor obstetrical life scores and significantly
Objective: and will verbalize appropriately and
history raise their anxiety scores Acknowledgment of should be able to
during subsequent feelings of anxiety
Increase in properly. patients feelings show positive
validates the feelings coping methods.
blood
Long-term goal: and communicates
pressure
acceptance of those
(150/100)
After 1 day, feelings.
patient will be Criteria:
Feelings of able to Maintain a calm and
helplessness tolerant manner while Patient verbalized
demonstrate
interacting with the feelings of anxiety
positive coping
Worry methods. (e.g. patient. properly and
showed healthy
Rationale: ways on how to
Fearfulness deal with anxiety.
The patients feeling
of stability increases
in a clam and
nonthreatening
atmosphere.

Reduce sensory
stimuli by maintaining
a quiet environment.

Rationale:

Anxiety may escalate

with excessive
conversation and
noise.

Encourage patient to
talk about anxious
feelings.

Avoid false
reassurances.

Rationale:

False reassurances
can increase level of
anxiety.

Assist in developing
anxiety-reducing skills
(relaxation, deep
breathing, positive
visualization,
reassuring self-
statements, etc.)

Rationale:
 IX. Related Readings
https://en.wikipedia.org/wiki/Stillbirth

http://emedicine.medscape.com/article/259165-overview

http://www.womens-health-advice.com/pregnancy-complications/intrauterine-fetal-death.html

https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_55.pdf