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PBL: Pregnancy with heart disease The 18 years old pregnant woman G2…

- - - - Breastfeeding: Suckling elevates prolactin, reduces GnRH, LH, inhibit follicular maturation
      - Fertility awareness: dry days after period until mucous is detected, the fourth day after peak mucous day
      - Condom
      - Vaginal spermicides: Predispose to E.coli bacterium
      - Vaginal barriers: Diaphragm, Cap, Sponge
      - Coitus interruptus: Withdrawal of the penis from the vagina before ejaculation
    - - Oral pill: Start at day 1-5 of menstrual cycle, administration at the same time, except combine pill
      - Injection: Single intramuscular shot
      - Implant: Implanon (1 rod / 3 years), Jadelle (2 rods / 5 years), Norplant (6 rods / 5 years)
    - - Sterilization:
        
        Male sterilization: vasectomy
        
        Female sterilization: Postpartum sterilization abdominal tubal resection (ATR), Interval sterilization suprapubic tubal resection (STR),laparoscopic tubal resection (LTR)
- - - - At the hospital
        
        Laboratory examination
        
        Urine Analysis: Protein&sugar negative.
        
        Abdominal Examination:
        
        Fundal height 32 cm, fatal position: LOA, head engage
        
        FHR=152 b/m regular, uterine contraction; duration=60", interval 2', intensity=strong
        
        Treatment
        
        Ampicillin 2 gm. IV push
        
        Treat for prevent infection of fetus.
        
        Gentamicin 80 mg. + 5% D/W 100 ml IV drip within 30 min.
        
        Evaluation: 1)Client has no fetal distress.
        2)Client has effective uterine contraction and normal fetal
        heart sound
        3)Cervical dilatation is along with the alert line of parthograph if in active phase.
        4)Encourage client to avoid position of supine position to prevent decreased venous blood return.
        
        Analysis: According to client has underlying disease about rheumatic heart disease and she has uterine contraction as well, these reasons can cause uteroinsufficiency then can cause the fetal distress in the further.
        
        Risk for heart failure related to Rheumatic heart disease.
        
        Supportive data; -Subjective data: None, -Objective data: BP=120/80 mmHg,PR=72 T/m,heart regulation rhythm, Systolic murmur gr. IV
        
        Nursing Interventions: 1)Monitor client's vital signs including blood pressure, pulse rate, respiratory rate, oxygen saturation.
        2)Provide oxygen therapy by using oxygen canula 4-5 LPM to the client
        3)Avoid client to perform pushing during give birth by using Forceps delivery
        4)Monitor uterine contraction every 30 minutes if client is in active phase.
        5)Avoid position client to be in the lithotomy position to prevent decreased venous blood return.
        6)Encourage client to perform absolute bed rest.
        7)Avoid Ergometrine to prevent hypertension and heart failure.
        
        Evaluation: 1)Client's vital signs is in the normal range according to her baseline.
        2)Client has effective uterine contraction.
        3)Client has no high blood pressure and no signs and symptoms of heart failure.
        4)Client able to perform absolute bed rest.
        5)client has no pushing during giving birth.
        
        Analysis:Pregnancy stresses the cardiovascular system, stresses include decreased hemoglobin and increased blood volume, stroke volume, and especially heart rate.During labor, cardiac output increases in each uterine contraction; other stresses include straining during the 2nd stage of labor and the increase in venous blood returning to the heart from the contracting uterus. Cardiovascular stresses do not return to prepregnancy levels until several weeks after delivery. And it can cause heart failure for the client.
        
        Physical Examination
        
        BP=120/80 mmHg,PR=72 T/m,RR=20 T/m,chest and lung are clear,heart regulation rhythm, Systolic murmur gr. IV