COLLEGE OF NURSING

MADURAI MEDICAL COLLEGE

MADURAI – 20

HIGH RISK- ANTENATAL CARE STUDY

ON
OLIGOHYDRAMNIOS
SUBMITTED TO:
MRS. SOBANA JOY JOHNSON, M.SC. (N), M. Sc(Psy)
READER IN NURSING.
MRS.N. RAJALAKSHMI, M.SC. (N).
MRS. S.SARUMATHI, M.SC. (N).
NURSING TUTOR GRADE -2,
CON, MMC, MADURAI.

SUBMITTED BY
M.JEYAMANI,
II- YEAR M.SC (N),
CON, MMC, MADURAI

SUBMITTED ON: SIGNATURE OF THE FACULTY

 INDEX

S.NO CONTENT PAGE NO

1 Introduction

2 Demographic study

3 Obstetric study

4 Physical Assessment

5 Obstetrical examination

Investigations

7 Oligohydramnios- Disease condition

8 Theory application

9 Nursing diagnosis

10 Health education

11 Bibliography

12 Conclusion
 INTRODUCTION

Several conditions have been associated with diminished amnionic fluid. Oligohydramnios almost

always is evident when there is either obstruction of the fetal urinary tract or renal agenesis. Therefore,

anuria almost certainly has an etiological role in such cases. A chronic leak from a defect in the fetal

membranes may reduce the volume of fluid appreciably, but most often labor soon ensues. Exposure to

angiotensin converting enzyme inhibitors has been associated with oligohydramnios. Anywhere from 15 to

25 percent of cases are associated with the fetal anomalies. Pryde and co-workers (2000) were able to

visualize fetal structures in only half of women referred for ultrasonic evaluation of mid trimester

oligohydramnios. They performed amnio infusion and were then able to visualize 77 percent of routinely

imaged structures. Identification of associated anomalies increased from12 to 31 percent of fetuses.

In severe cases, a continuing increase in the amount of amniotic fluid threatens the pregnancy, which may

end in premature delivery. Particular attention must be paid to assisting the baby in getting into a favorable

position for the birth. The amniotic sac must not be allowed to rupture so that there is a sudden loss of

amniotic fluid; this could cause a cold prolapse or a placental abruption. The birth attendants must be alert to

prevent and treat possible postpartum hemorrhage.

I am M. Jeyamani II Year M. Sc Nursing student . Iam posted in the Antenatal ward. I had an

opportunity to give comprehensive nursing care to the patient. I have selected my client

Mrs. Sangeetha I had opportunity to learn about oligohydramnios and its management .
OBJECTIVES OF THE CARE STUDY:

o Establish rapport with the client and her family members.

o To do complete physical assessment for the client with oligohydramnios

o To identify the nursing needs of the client.

o To formulate the nursing diagnosis for oligohydramnios

o To acquire the knowledge and understanding about oligohydramnios

o To provide comprehensive nursing care of the client.

o To restore the normal activity of the client as soon as possible and to alleviate fear and

anxiety of the client.

o To prevent further complication through effective nursing management.

o To educate patient and family members regarding different aspect of disease and

management.
DEMOGRAPHIC DATA

PROFILE OF THE MOTHER:

Name of the mother : Mrs. Sangeetha

Age : 25yrs

Educational status : 10th Std

Occupation : House wife

Nationality : Indian

Religion : Hindu

Address : W/o Mr. Suresh

C15,TNHP Colony, Aanaiyur, Madurai.

Marital Status : Married

Name of the Hospital : Government Rajaji Hospital

Date of Admission : 15.04.2022 at 12.35 pm

Ward : Antenatal ward

Unit : III Unit

L.M.P : 18/08/2021

E.D.D : 25/5/2022

Obstetric Score : G2 P1 L1 A0

Weeks of gestation : 35 weeks 2 days

Diagnosis : Hydramnios complicating pregnancy

Informant : Mother and case sheet

PROFILE OF THE HUSBAND:

Name of the husband : : Mr. Suresh

Age : 30yrs

Educational Status : X Std

Occupation : cooly

Income : Rs. 8000/ month

Reason For Hospitalization

In her third trimester she developed with hydramnios.. She is admitted in antenatal ward for safe

confinement of pregnancy.

Present Medical History

She is not having hypertension, GDM, Thyroid diseases.

Past Medical / Surgical History:

She had PCOD past 2yrs and took treatment and cured.

History of blood transfusion in first pregnancy.

Personal History:

She consumes mixed diet and doesn’t have allergy to any food. She has the habit of drinking tea and

coffee. She takes three meals per day and 2 snacks per day. She sleeps 6 hrs per night and 2 hrs per day. She

doesn’t face any difficulties in the basic activities. She maintained good personal hygiene. She had bowel

elimination 2 times per day and urination 6 times per day and 3 times per night, and she is interested in

watching T.V and listening music. She had received two doses of Td immunization.
Menstural History:

She attained menarche at the age of 15 yrs. She had regular menstrual cycle of 5/30 days and the

amount of flow is 50 ml per cycle. She had no complaints during menstruation.

Marital History:

She got married at the age of 25yrs and the duration of marriage is three years and the type of

marriage is consanguineous marriage – III0.

Contraceptives:

She did not use any contraceptives.

Family History

There is a no family history of hypertension, diabetic mellitus, cardiac diseases, epilepsy and

communicable diseases. There is no history of multiple pregnancy and congenital anomalies.

Family Pedigree:

65yrs 60yrs 53yrs 59yrs

39yrs 37yrs 32yrs 29yrs 27yrs 25yrs

4yrs PP
 Key Note:
Female

Male

Client

Present pregnancy

Socioeconomic Status:

She belongs to a middle class family.The client’s husband is the bread winner of the family and she

is a home maker. She belongs to the Nuclear family and their total income is Rs. 8,000 per month. They live

in rent house with closed drainage system, adequate water and electricity facilities present and using

Corporation water for drinking and washing purpose.

Obstetrical History:

a. Past Obstetrical History:

S. Mon Mother Baby

no
& Compli- Abortion Complication Sex Birth Condition Health

during at Birth
Year cations /Preterm Type of Wt Status

Puerperium
During /Full term Delivery

Pregnacy

1 2018 uneventful Full term NVD uneventful Fem 2.5 Kg Good Healthy

ale

2 2022 Present pregnancy

Present Obstetrical History:

The mother is booked her pregnancy in her native place and took regular antenatal checkup.. She had

first trimester minor ailments like nausea and vomiting. In her third trimester she is developed with

hydramnios.. She is admitted Government Rajaji Hospital in antenatal ward for safe confinement.

I ST TRIMESTER

 Pregnancy confirmed by UPT ,

 Inj. Td first dose immunized.

 Routine investigation done

 Dating scan taken Tab. Folic acid 5mg given, no h/o weight gain .h/o vomiting present.

II TRIMESTER

 Quickening felt at 5 th month .

 INJ.Td 2 nd dose immunized.

 Anomaly scan taken.

 T.FST and T. Calcium taken.

 No h/o excessive weight gain.

III TRIMESTER

 Lightening is present,

 Maturity scan taken,

 Foetal movement present ,

 No h/o pedal edema, no h/o vaginal bleeding.

Antenatal Attendance:

Date Wt in Urine B.p Wks of Ht of Presentati FHR Treatment

gestation fundus on
Kg Mm/Hg per And

in cm remarks
Alb Sugar minute

11.11.21 34 Nil Nil 120/80 12weeks - - 136

Taken iron,

ferrous

sulphate,
12.12.21 35 Nil Nil 110/80 16 weeks 20 cm - 138
calcium

supplements

16.02.22 37 Nil Nil 100/60 26weeks 26 cm Cephalic 138

14.03.22 39 Nil Nil 110/80 29 weeks 26 cm Cephalic 136

21.04.22 39 Nil Nil 110/70 35 weeks 30 cm Cephalic 142

 PHYSICAL EXAMINATION

General condition:

Height : 148cms

Weight : 61 Kgs

BMI : 27.8

Gait : Waddling gait

Vital signs:

Temperature : 98.6o F

Pulse : 84 beats / min

Respiration : 20 breaths / min

B.P : 110/70 mm Hg

General appearance:

Body built : Moderate Body Built

Healthy Status : Oligohydramnios

Activity : Good

Mental Stasus:

Orientation : Oriented to date, time place and person

Facial expression : Good

Any other : Nil

Head:

Hair : Black in colour, evenly distributed hair, No dandruff, pediculosis

Texture : Dry

Scalp : Clean

Face:

Pallor : Present

Oedema : No edema found

Cholasma : No cholasma found

Any other : Absent

Eyes:

Vision : Visual acuity present

Pupillary reaction : Both sides equally reacting to light

Conjunctiva : Pale in colour

Any other : Nil

Ears:

Hearing : Hearing acuity is good

Any other : Nil

Nose:

Septal deviation : No septal deviation

Any other : Nil

Mouth:

Lips : Pale in colour

Tongue : No coated tongue

Teeth : No dental caries

Any other : Nil

Neck:

Lymph nodes : No palpable lymph nodes

Thyroid : No thyroid enlargement

Any other : Nil

Chest:

Shape : Normal in shape

Movement : Symmetrical

Respiration : 20 breaths per minute

Breath sound : Normal vesicular Breath Sound

Heart rate : 84 beat per minute

Murmur : No murmur heard

Any other : Nil

EXTREMITIES:

Pulsation : Present

Symmetrical : Symmetrical

Oedema : Bilateral pedal edema absent

Varicose veins : No varicose veins found

Axilla : No palpable lymph nodes found

Reflexes : All the reflexes are normal

ROM : All the range of motions is normal

Any other : Nil

BACK:

Deformity : No deformity found

Sacral edema : No sacral edema found

Any other : Nil

OBSTETRICAL EXAMINATION:

Breast:

Symmetry : Symmetrical

Veins : No distended veins

Areola primary : Present

Areola Secondary : Present

Montgomery Tubercles : Prominent

Nipple protractility : Erect

Any other : Nil

Perineum:

Hygiene : Clean and free from infection

Discharges : Free from discharges

Bleeding : Free from bleeding

Any other : Nil

Abdomen:

Inspection:

Shape : ovoid in shape

Size : Size is smaller than the gestational age
Contour : Firm
Lightening : Not present
Umbilicus : Slightly protruded
Skin changes : Linea Niagara, Striae gravidarum is present
Foetal movements : Visible foetal movements
Scar : No previous scar
Any other : Nil
PALPATION:

Height of fundus : 34cms

Finger breadth method : 35 weeks
Abdominal girth : 86cms
Fundal palpation : Broad soft,soft,boggy mass felt at the upper pole of the uterus.

Itindicate the presence of foetal buttocks

Lateral palpation:

Right: Small irregular buds like projection felt at right side of mothers abdomen.

It indicates foetal limbs

Left : A continuous ,Uniform, regular C shaped curvature felt at the left side of ,mothers
abdomen. It indicates foetal spine

PELVIC PALPATION:

Pelvic grip I: Convergent, and hard mass felt at the lower pole of the uterus indicate the presence of
fetal head.

Pelvic grip II: Ballotable hard mass felt. Head is Unengaged.

Grip I is confirmed by pelvic grip II.

Auscultation: 140 beats per minute

Location :Midway between the umbilicus and anterior superior iliac spine.

Rhythm :Regular
SUMMARY OF FINDINGS:

LIE : Longitudinal

ATTITUDE : Complete flexion

PRESENTATION : Cephalic

POSITION : Leftoccipito anterior

ENGAGEMENT : Not engaged

FHR PER MINUTE : 140 per minute

SYSTEMIC EXAMINATION

Cardiovascular system:

Inspection : The size & symmetry of the chest are equal.

Palpation : Heart rate is 78 beats / mint

Auscultation: S1& S2 Sound is heard. S1 is the sound heard at the base of the heart,

S2 is heard over the left inter coastal space.

Respiratory System:

Inspection : Thoracic respirations are present. Respiratory rate is 24 breaths are present.

Palpation: Thoracic expansion from the anterior & posterior side is normal.

Percussion: Resonance sound is heard over the third & the fourth intercostals pace.

Auscultation: Broncho vesicular breath sound is heard.

Gastro intestinal system:

Inspection: Round in shape. Umbilicus is protruded. Bowel sound is heard on all the four
quadrants of the abdomen, & abdominal respirations are present.

Central Nervous System: Conscious, oriented to date, place, time & person

Loco Motor System: Muscle tone is good, Range of motion is good.

Integumentary System: Dry skin present. Nail buds are pale in colour.

Muscle tone is good

Linea niagra and striae gravidae present

Genitourinary System: She voids urine 8 times per day

Investigations:

S.no Blood investigations Patient value Normal value Remarks

1 Haemoglobin 12.0gms/dl 12-14 gms /dl Normal

2. Blood Glucose(R) 78mgs/dl 80-120 mg/dl Decreased

Urea 16mgs/dl 20-40mgs/dl Normal

Creatinine 0.8mgs/dl 0.5-1.5mgs/dl Normal

3. Total Bilirubin 0.5mg/dl 0.5-1.2mgs/dl Normal

4. SGOT (AST) 18 IU/L 20-40 IU/L Decreased

SGPT (ALT) 05 IU/L 20-40 IU/L Decreased

5. Glucose Challenge 103mgs/dl 80-120mgs/dl Normal

Test (GCT)

2 Urine albumin sugar Nil Nil Normal

3 Blood group AB Positive - -

4 VDRL Non reactive Negative Normal

Ultrasound report:

Single Live Intra Uterine Pregnancy (SLIUG)

Presentation : Cephalic

Biparietal diameter : 9.2 cm

Liquor : less than normal

Placenta : Posterior

Gestational age : 37 weeks

FHR : 142/min

AFI : 7cms
 MEDICATIONS

S.NO NAME OF DOSAGE MODE OF ACTION INDICATIONS CONTRA- SIDE NURSES

THE DRUG EFFECTS RESPONSIBILITY
/ROUTE/ INDICATIONS

FREQUENCY

1. T. Ferrous 333 mg and 0.5 Iron absorbed in the GI Iron deficiency Haemo siderosis Constipation Follow six rights
sulphate and mg Folic acid tract through the anemia
folic acid mucosal cell where it Peptic ulcer Gastric Client use of antacid and
confines with the protein Prophylaxis in irritation other drugs may interact
transferrin. This Pregnancy with their preparation.
Nausea
complex is transported Instruct the mother that
to bone marrow to Abdominal the stool may black in
produce Hb cramping colour
Vomiting

2. T. Calcium Cancer with GI irritation

It is necessary for Acute Monitor for calcium level
500 mg/ 300 mg metastasis
activation of many hypocalcaemia
oral/od Constipation
enzyme reaction and is
Tetany
required for impulses
contraction of cardiac
and skeletal muscles
3. Inj.Dexamethazo 6mg /IM/ BD Anti inflammatory and Arthritis, blood Untreated TB, Upset stomach, Not give nursing mothers
ne immunosuppressive disorders, Herpes simplex vomiting, head
effects and inhibition of breathing infection, fungal ache. Increase dosage when
inflammatory cells. problems. infection. patient is stress.

4. T.Sildenafil 25 mg/BD It also dilatation of the Eretile Headache, Hypotension, Consuming high fat
blood vessels in the dysfunction, and Heartburn, meal, monitor chest pain,
lungs. increased blood flushed skin Hearing loss Headache, and Blurred
flow. vision.
 OLIGOHYDRAMNIOS

INTRODUCTION:
Amniotic fluid is vital to the well-being of the fetus. It cushions the fetus from injury,

helps prevent compression of the umbilical cord, and allows room for it to move and grow. In

addition, its bacteriostatic action helps prevent infection of the intra-amniotic environment.

The quantity of amniotic fluid at any time in gestation is the product of water exchange

between the mother, fetus, and placenta, and is maintained within a relatively narrow range.

Disorders of this regulatory process can lead to either polyhydramnios or oligohydramnios, in

which too much or too little fluid exists, respectively. These disorders may result from

abnormal fetal or maternal conditions and, conversely, may be responsible for alterations of

fetal well-being as well. With the advent of real-time ultrasonography, assessment of

amniotic fluid has been possible, resulting in earlier recognition of abnormal conditions and

possible intervention. Because precise quantification of amniotic fluid volume is not possible

with ultrasonography, various techniques for both qualitative and semi quantitative

assessment have been proposed. This chapter reviews the dynamics of amniotic fluid volume

(Fig. 1), discusses the causality and perinatal significance of volume disturbances, and

reviews the techniques of ultrasonographic assessment of amniotic fluid volume, as well as

their role in the antenatal testing of high-risk fetuses.

AMNIOTIC FLUID

At term, the fetus is submerged in about 1 liter of clear watery fluid (though

up to 2 liters normally may be present). The amniotic fluid has a low specific gravity (_1.008)
and mild alkalinity (pH _7.2). The amniotic fluid protects the fetus from direct injury, aids in

maintaining its temperature, allows free movement of the fetus, minimizes the likelihood of

adherence of the fetus to the amniotic membrane, and allows for hormonal, fluid, and

electrolyte exchange. It acts as a repository for fetal secretions and excretions. It contains

fetal squamous debris, flecks of vernix, a few leukocytes, and small quantities of albumin,

urates, and other organic and inorganic salts.

Hormones and alpha fetoprotein (AFP), a protein produced by the fetus, also

are found in the amniotic fluid. The electrolyte concentration is equivalent to that of maternal

plasma except for calcium, which is lower (5.5 mg/mL). Amniotic fluid is variously

considered to be a secretion of the amnion, a vascular transudate, or fetal urine. All three

sources contribute to its formation in varying amounts at different times in gestation. For

example, with lengthening gestations, fetal urine becomes a more important contributor.

There is rapid amniotic fluid turnover (_350–375 mL/h). Retention of only a few milliliters

per hour soon will result in polyhydramnios (_2 liters of amniotic fluid), whereas excessive

reabsorption or failure of production will cause oligohydramnios (_300 mL of amniotic fluid

at term).
Amniotic fluid index (AFI) is kind of an estimate of the amount of amniotic fluid and is an

index for the fetal well-being. It is a part of the biophysical profile. AFI is the score

(expressed in cm) given to the amount of amniotic fluid seen on ultrasonography of a

pregnant uterus. To determine the AFI, doctors may use a four-quadrant technique, when the

deepest, unobstructed, vertical length of each pocket of fluid is measured in each quadrant

and then added up to the others, or the so-called "Single Deepest Pocket" technique.

 An AFI between 8-18 is considered normal. Median AFI level is approximately 14

from week 20 to week 35, when the amniotic fluid begins to reduce in preparation for

birth.
  An AFI < 5-6 is considered as Oligohydramnios. The exact number can vary by

gestational age. The fifth percentile for gestational age is sometimes used as a cut off

value.

 An AFI > 20-24 is considered as Polyhydramnios.

DISORDERS OF AMNIOTIC FLUID

The amniotic fluid reaches its maximum volume of about 800 mL at about 28

weeks. This volume is maintained until close to term when it begins to fall to about 500 mL

at week 40. The balance of fluid is maintained by production of the fetal kidneys and lungs

and resorption by fetal swallowing and the interface between the membranes and the

placenta. A disturbance in any of these functions may lead to a pathologic change in amniotic

fluid volume.

Ultrasound can be used to evaluate the amniotic fluid volume. The classic

measure of amniotic fluid is the amniotic fluid index (AFI). The AFI is calculated by

dividing the maternal abdomen into quadrants, measuring the largest vertical pocket of fluid

in each quadrant in centimeters, and summing them. An AFI of less than 5 is considered

oligohydramnios. An AFI greater than 20 or 25 is used to diagnose polyhydramnios,

depending on gestational age.

OLIGOHYDRAMNIOS

Oligohydramnios in the absence of rupture of membranes is associated with a 40-fold

increase in perinatal mortality. This is partially because without the amniotic fluid to cushion

it, the umbilical cord is more susceptible to compression leading to fetal asphyxiation. It is

also associated with congenital anomalies, particularly of the genitourinary system, and

growth restriction. In labor, nonreactive non-stress tests, fetal heart rate (FHR) decelerations,
meconium, and cesarean section due to non reassuring fetal testing are all associated with an

AFI of less than 5.

ETIOLOGY

The cause of oligohydramnios can be thought of as either decreased production or

increased withdrawal. Amniotic fluid is produced by the fetal kidneys and lungs. It can be

reabsorbed by the placenta, swallowed by the fetus, or leaked out into the vagina.

 Chronic uteroplacental insufficiency (UPI) can lead to oligohydramnios because the

fetus likely does not have the nutrients or blood volume to maintain an adequate

glomerular filtration rate. UPI is commonly associated with growth-restricted infants.

 Congenital abnormalities of the genitourinary tract can lead to decreased urine

production. These malformations include renal agenesis (Potter syndrome), polycystic

kidney disease, or obstruction of the genitourinary system.

 The most common cause of oligohydramnios is rupture of membranes.

 Even without a history of leaking fluid, the patient should be examined to rule out this

possibility.

MATERNAL CAUSE

 Hypertensive disorders
  Utero placental insufficiency

 Dehydration

 Idiopathic

FETAL CONDITIONS

 Fetal chromosomal or structural abnormalities

 Renal agenesis

 Obstructed uropathy

 Spontaneous rupture of memberane

 Intrauterine infection

 Drugs: PG inhibitors, ACE inhibitors

 Post maturity

 IUGR

 Amnion nodosum ( failure of secretion by the cells of the amnion covering the

placenta)

OLIGOHYDRAMNIOS TETRAD
The oligohydramnios tetrad, initially called Potter’s syndrome, includes agenesis of the

kidneys resulting in oligohydramnios, pulmonary hypoplasia, spadelike hands and feet,

peculiar facies with a beaked nose, and creases under the lower eyelids. The fetus, often

SGA, usually is in a breech position, does not tolerate the stress of labor, and may be

stillborn. When liveborn, the neonate has immediate respiratory distress and dies of

respiratory failure long before it could die of renal failure.

Oligohydramnios is associated with fetal anuria. Renal agenesis per se is not the

cause of pulmonary hypoplasia, however, which is the result of lack of amniotic fluid and

thoracic constraint. Oligohydramnios without renal agenesis also can cause pulmonary

hypoplasia (e.g., prolonged rupture of membranes with continued leakage). Deformation of

the face and extremities plus arthrogryposis is usual in long-standing oligohydramnios.

DIAGNOSIS

Diagnosis of oligohydramnios is made by

 AFI less than 5 as measured by ultrasound. Patients screened for oligohydramnios

include those measuring size less than dates,

 History of ruptured membranes,

 Suspicion of IUGR, and

 Post term pregnancy.

DIAGNOSIS:

1. Uterine size is smaller than the period of amenorrhea

2. Less fetal movements

3. The uterus is full of fetus because of scanty liquor

4. Malpresentation is common

5. Evidences intrauterine growth restriction of fetus

6. Sonographic diagnosis is made when largest liquor pool is less than 2 cms.
 7. Visualization of normal filling and emptying of fetal bladder essesntially rules out

urinary tract abnormality.

MANAGEMENT

 Counselling
 Consider Amnio infusion
 Serial USG
 Exclude PPROM
 Termination of pregnancy SOS
 Deliver post term cases
 Serial USG and Doppler in IUGR
 Conservative management for preterm prelabor rupture of membranes till 34 weeks
 Maternal hydration :1500-2000ml/day ( oral/ IV)
 Amnio infusion Abdominally/ trans cervically

TREATMENT

Management of oligohydramnios is entirely dependent on the underlying

etiology. In pregnancies that are IUGR, a host of other data needs consideration, including

the rest of the biophysical profile (BPP), umbilical artery Doppler flow, gestational age, and

the cause of the IUGR. Labor is usually induced in the case of a pregnancy at term or

postdate. In the case of a fetus with congenital abnormalities, the patient should be referred to

genetic counseling. A plan for delivery should be made in coordination with the pediatricians

and pediatric surgeons. Severely preterm patients with no other etiology are usually managed

expectantly with frequent antenatal fetal testing. Labor is induced in patients with rupture of

membranes at term if they are not already in labor. If there is meconium or frequent

decelerations in the FHR, an amnio infusion may be performed to increase the AFI.

Amnioinfusion is performed to dilute any meconium present in the amniotic fluid and

theoretically to decrease the number of variable decelerations caused by cord compression.

PROPHYLACTIC AMNIOINFUSION FOR OLIGOHYDRAMNIOS.

 Amnioinfusion for oligohydramnios has been used prophylactically in an effort to

avoid intrapartum fetal heart rate patterns from umbilical cord occlusion. Nageotte and

coworkers (1991) found that such amnio infusion resulted in significantly decreased

frequency and severity of variable decelerations in labor. There was no improvement,

however, in the cesarean delivery rate or condition of term infants. In a

randomized investigation, Macri and co-workers (1992) studied prophylactic amnio infusion

in 170 term and post term pregnancies complicated by both thick meconium and

oligohydramnios. Amnioinfusion significantly reduced cesarean delivery rates for fetal

distress as well as meconium aspiration syndrome. In contrast, Ogundipe and associates

(1994) randomly assigned 116 term pregnancies with an amnionic fluid index of less than 5

cm to receive prophylactic amnio infusion or standard obstetrical care. There were no

significant differences in overall cesarean delivery rates, delivery rates for fetal distress, or

umbilical gas studies.

EARLY-ONSET OLIGOHYDRAMNIOS.

Several conditions have been associated with diminished amnionic fluid.

Oligohydramnios almost always is evident when there is either obstruction of the fetal

urinary tract or renal agenesis. Therefore, anuria almost certainly has an etiological role in

such cases. A chronic leak from a defect in the fetal membranes may reduce the volume of

fluid appreciably, but most often labor soon ensues. Exposure to angiotensin converting

enzyme inhibitors has been associated with oligohydramnios Anywhere from 15 to 25

percent of cases are associated with the fetal anomalies. Pryde and co-workers (2000) were

able to visualize fetal structures in only half of women referred for ultrasonic evaluation of

midtrimester oligohydramnios. They performed amnioinfusion and were then able to

visualize 77 percent of routinely imaged structures. Identification of associated anomalies

increased from12 to 31 percent of fetuses.

PROGNOSIS:

Fetal outcome is poor with early-onset oligohydramnios. Shenker and colleagues

(1991) described 80 pregnancies and only half of these fetuses survived. Mercer and Brown

(1986) described 34 mid trimester pregnancies complicated by oligohydramnios diagnosed

ultrasonically by the absence of amnionic fluid pockets greater than 1 cm. Nine fetuses (one

fourth) had anomalies, and 10 of the 25 who were phenotypically normal either aborted

spontaneously or were stillborn because of severe maternal hypertension, restricted fetal

growth, or placental abruption. Of the 14 live born infants, eight were preterm and seven

died. The six infants who were delivered at term did well. Garmel and co-workers (1997)

observed that appropriately grown fetuses associated with oligohydramnios prior to 37 weeks

had a threefold increase in preterm birth but not of later growth restriction or fetal death. New

bould and colleagues (1994) described autopsy findings in 89 infants with the

oligohydramnios sequence or Potter syndrome. Only 3 percent had a normal renal tract; 3

percent had bilateral renal agenesis; 34 percent, bilateral cystic dysplasia; 9 percent, unilateral

agenesis with dysplasia; and 10 percent, minor urinary abnormalities. Otherwise normal

infants may suffer the consequences of early-onset severely diminished amnionic fluid.

Adhesions between the amnion may entrap fetal parts and cause serious deformities,

including amputation. Moreover subjected to pressure from all sides, musculoskeletal

deformities such as clubfoot are observed frequently.

OLIGOHYDRAMNIOS IN LATE PREGNANCY. ,

 Amnionic fluid volume diminishes normally after 35 weeks. Management of

oligo hydramnios in late pregnancy depends on the clinical situation. An evaluation for fetal

anomalies and growth is critical. In a pregnancy complicated by oligo hydramnios and fetal

growth restriction, close fetal surveillance is important because of associated morbidity, and

delivery is recommended for fetal or maternal indications. Although gestational age is

considered in this decision, evidence for fetal or maternal compromise Normal-sized lungs

(top) are shown in comparison with hypoplastic lungs (bottom) of fetuses at the same

gestational age. (From Newbould and colleagues, 1994, with permission.) usually overrides

potential complications from preterm delivery. Oligohydramnios detected before 36 weeks in

the presence of normal fetal anatomy and growth may be managed expectantly in conjunction

with antepartum fetal testing discussed in Oz and colleagues (2002) investigated the etiology

of oligohydramnios in post term pregnancy. They found a reduction in renal artery end-

diastolic velocity, suggesting that increased arterial impedance is an important factor. Using

an amnionic fluid index of less that 5 cm, Casey and co-workers (2000) found an incidence of

oligohydramnios of 2.3 percent in more than 6400 pregnancies undergoing sonography after

34 weeks at Parkland Hospital. They confirmed previous observations that this finding is

associated with an increased risk of adverse perinatal outcomes (Table 21-6). Conversely,

using the RADIUS trial database, Zhang and colleagues (2004) reported that

oligohydramnios of this degree was not associated with adverse perinatal outcomes.

Similarly, Magann and co-workers (1999) did not find that associated oligohydramnios

increased risks for intrapartum complications.

Chauhan and associates (1999) performed meta-analysis of 18 studies comprising

more than 10,500 pregnancies in which the intrapartum amnionic fluid index was less than 5

cm. Compared with controls whose index was over 5 cm, women with oligohydramnios had a

significantly increased, 2.2-fold, risk for cesarean delivery for fetal distress and a 5.2-fold
increased risk for a 5-minute Apgar score of less than 7. Cord compression during labor is

common with oligohydramnios. Sarno and co-workers (1989, 1990) reported that an index of

5 cm or less was associated with a fivefold increased cesarean delivery rate. Baron and

colleagues (1995) reported a 50- percent increase in variable decelerations during labor and a

sevenfold increased cesarean delivery rate in these women. By contrast, Casey and co-

workers (2000) showed a 25-percent increase in non reassuring fetal heart rate patterns when

women with oligohydramnios were compared with normal controls. Moreover, the cesarean

rate for pregnancies with this finding increased only from 3 to 5 perce

Divon and associates (1995) studied 638 women with a post term pregnancy in labor and

observed that only those whose amnionic fluid index was 5 cm or less had fetal heart rate

decelerations and meconium. Interestingly, Chauhan and collaborators (1995) showed that

diminished amnionic fluid index increased the cesarean delivery rate only in women whose

labor attendants were made aware of the findings.

AMNIO infusion

Results with intrapartum amnioinfusion to prevent fetal morbidity from meconium-stained

fluid often associated with oligohydramnios are mixed. Pierce and colleagues (2000)

performed meta-analysis of 13 studies with 1924 such women randomized to amnioinfusion

or no treatment. They found that amnio infusion resulted in significantly decreased adverse

outcomes: meconium beneath the cords (OR 0.18), meconium aspiration syndrome (OR

0.30), neonatal acidemia (OR 0.42), and cesarean delivery rate (0.74). Conversely, Sponge

and associates (1994 found no benefits when they compared therapeutic with prophylactic

amnio infusion for meconium. Indeed, meconium aspiration syndrome occurred only in the

group undergoing therapeutic amnio infusion. Surprisingly, only 16 percent of the group

randomized to expectant therapy ultimately required amnio infusion for variable fetal heart
rate decelerations. These findings are in agreement with reviews of outcomes before and after

amnio infusion protocols were implemented (DeMeeus and colleagues, 1998; Rogers and

colleagues, 1996;

Usta and colleagues 1995). Taken together these results suggest that routine prophylactic

amnio infusion for meconium is not warranted. Post term fetuses were described by Leveno

and associates (1984). They reported that both antepartum fetal jeopardy and intrapartum

fetal distress were the consequence of cord compression associated with oligohydramnios. In

their analysis of 727 post term pregnancies, intrapartum fetal distress detected with electronic

monitoring was not associated with late decelerations characteristic of uteroplacental

insufficiency. Instead, one or more prolonged decelerations, preceded three fourths of

emergency cesarean deliveries for fetal jeopardy. In all but two cases, there were also

variable decelerations. These findings are consistent with cord occlusion as the proximate

cause of fetal distress. Other correlates found were oligohydramnios and viscous meconium.

Decreased amniotic fluid volume commonly develops as pregnancy advances beyond 42

weeks. It is also likely that meconium release into an already reduced amnionic fluid volume

causes thick, viscous meconium implicated in meconium aspiration syndrome.

COMPLICATIONS

Maternal:

 Prolonged due to inertia,

 increased operative interferences due to malpresentation.

Fetal:

 Abortion
  Deformity due to intra amniotic adhesions due to compression, the deformities

include alteration in shape of the skull, wry neck, club foot or even amputation

of the limb,

 Fetal pulmonary hypoplasia ( may be the cause or effect),

 Cord compression,

 High fetal mortality.

NURSING DIAGNOSES
 Deficient fluid volume related to bleeding and decreased fluid intake evidenced

by dryness of lips and tongue

 Acute pain related to compression of gravid uterus over maternal spine secondary

to pregnancy as evidenced by facial expression

 Anxiety related to outcome of labour secondary to pregnancy as evidenced by

panic face.

 Activity intolerance related to big gravid uterus and it is evidenced by fatigue.

 Imbalance nutrition less than body requirements related to unawareness of iron

content foods evidenced by assessing the diet pattern

 Knowledge deficit regarding the disease condition and the care of the baby.

 Risk for infection related to low immune status evidenced by low haemoglobin

level and repeated invasive procedure.

 Sleep pattern disturbance related to gravid uterus evidenced by dull look and

fatigue.
Subjective data : The patient verbalizes that she had thirst.

Objective data : She looks fatigue.

Diagnosis : Deficient fluid volume related to bleeding and decreased fluid intake evidenced by dryness of lips and tongue
Goal : Maintain normal fluid volume.

S.NO PLAN OF ACTION IMPLEMENTATION RATIONALE EVALUATION

1. Assess the level of hydration Assessed the level of hydration. It gives baseline data. Normal fluid
volume is
2 Maintain intake and output Maintained intake and output chart. It helps to calculate the
maintained as
chart. volume of fluid to be infused
evidenced by skin
turgor is good

3. Encourage to take plenty of oral Encouraged to take plenty of oral fluids. It helps to improve the
fluids. hydration.

4. Administer intravenous fluids as Administered ringer lactate It improves hydration

per doctor’s order

5. Reassess the hydration level . Reassessed the hydration level . It helps for further planning .
SUBJECTIVE DATA : The patient says that she has pain over the lower back of the body

OBJECTIVE DATA : The mother has grimaced face

NURSING DIAGNOSIS : Acute Pain (Back pain) related to compression of gravid uterus over maternal spine secondary to pregnancy as evidenced by
facial expression

GOAL : The patient will be relieving from pain

PLAN OF ACTION RATIONALE IMPLEMENTATION EVALUATION

 Assessed the general condition

 Assess the general condition  It provides baseline data of
and pain level using pain scale
and pain level using pain the patient
scale
 Provide left lateral position  Provided left lateral position to The patient level of pain is reduced
 Relieves excess pressure
to the patient the patient as evidence by facial expression
over the back

 Provide comfort devices to

 Provided comfort devices to
the patient  It helps to relieve pain
the patient
 Provide diversion therapy
 Provided diversion therapy
like mild music to the
 Provided diversional therapy like mild music to the patient
patient
like mild music to the patient
 Advise the patient to wear
 Advised the patient to wear
flat slipper
flat slipper
 It helps to reduce the
pressure over the sacrum
SUBJECTIVEDATA : The mother said that she feels fear and anxiety asking about the time of delivery

OBJECTIVE DATA : Anxious, dull, starring look, repeatedly asking about labour process

NURSING DIAGNOSIS : Anxiety related to labour process as evidenced by asking more questions regarding labour process

GOAL : Helps to alleviate anxiety

PLAN OF ACTION IMPLEMENTATION RATIONALE EVALUATION

 Assess the level of anxiety of  Assessed the level of anxiety  Helps to know the level of
the patient using scale of the patient using anxiety anxiety of the patient using
scale scale

 Provided information  Helps to create awareness in

Provide information
regarding signs of labour the patient about the labour
regarding signs of labour
onset and when to call the process
onset and when to call the
health care provider The patients level of anxiety is
health care provider
reduced as evidenced by the mother
 Educate the mother about
looks comfortable and asks frequent
breathing exercise  Educated the mother about
 Helps to alleviate anxiety questions .
the deep breathing exercise

 Show her the recently

 Showed her the her the  It provides moral support to
delivered mother
recently delivered mother the patient
SUBJECTIVE DATA : The mother said that she feels very tired

OBJECTIVE DATA : She looks very tired

NURSING DIAGNOSIS : Activity intolerance related fatigue related to increased maternal demand secondary to pregnancy and compression of gravid
uterus as evidenced by exhausted face.

GOAL : The patient will improve the activity level

PLAN OF ACTION IMPLEMENTATION RATIONALE EVALUATION

 Assess the activity level of  Assessed the activity level of  It provides base line data
the patient the mother
 Provide rest period between  Provided rest period between
 It conserves energy of the
the activities activities
mother
The mothers activity level is
improved as evidenced by the
 Advise the patient to avoid  Advised the patient to avoid
mother looks comfortable.
strenuous activity strenuous activities
 It prevents fatigue

 Advise the patient to take

high calorie diet  Advised the mother to take
high calorie diet
 It provides energy
 Advise the patient to  Advised the patient to
decrease activity before decrease activity before
bedtime bedtime  It helps to promote sleep
 HEALTH EDUCATION

DIET:

 Advised the mother to reduce salt content in food and to avoid taking pickles

 Advised the mother to take protein rich food

 Advised the mother take iron rich food like green leafy vegetable such as spinach, cabbage

BREAST CARE:

 Explained the mother about the importance and techniques of breast feeding

 Educated the mother regarding cleaning of breast and nipples

HYGIENE:

 Advised the mother to maintain personal hygiene such as to take bath daily and wear clean

dress

 Advised the mother to keep the genital area clean and free from infection

REGARDING LABOUR:

 Educated the mother regarding labour process

 Educate the mother regarding signs of labour onset and when to call health care provider
CONCLUSION:

Oligohydramnios increases the risk of postpartum hemorrhage simply because the uterus has

been distended more than is usual for a singleton pregnancy. Thus, it can be more difficult for the uterus to

contract completely, and it is essential that a diligent watch be kept to ensure that clots do not accumulate,

thus making it even harder for the uterus to contract, thus causing more bleeding, more clots, etc. Diligent

attention to uterine size and hardness should provide ample warning of impending postpartum hemorrhage.

Massaging the uterus or nursing the baby (or otherwise stimulating the nipples) will help to keep the uterus

contracted. It may be necessary to augment this with oxytocin.

I thank our respected madam Mrs. SOBANA JOY JOHN, MSc (N), Vice Principal, Reader&

HOD of Obstetrics and Gynaecological Nursing and Mrs. RAJALAKSHMI M.Sc (N).,Nursing tutor grade

II, College of Nursing, Madurai Medical College, Madurai , for giving me this great opportunity to give care

to the antenatal mother with oligohydromnios during my clinical posting.

BIBLIOGRAPHY


 Annamma Jacob, (2004),”A comprehensive text book of midwifery”,(2 ndedition),Jaypee
brothers
 Basavanthappa B.T. (2006) Textbook of Midwifery and reproductive health nursing, I
edition, Newdelhi: Jaypee publishers.
 Dutta. D.C. (2004), “Text book of Obstetrics including Perinatology and
conctraception”, 6th edition, New Delhi, Central Book Agencies Pvt. Ltd.,
 DeitraleonardLowder milk and Shannon E Perry(2004), “Maternity and women’s
Health care”, 8th Edition, USA, Mosby Publications.
 Lynna Y. Littleton, Joan C. Engebretson (2007), “Maternity nursing care”, 1 st Edition,
Haryana, Thompson Delmer Learning
 Mudaliar A.L, M.K. Krishna Menon, (2004), “Clinical Obstetrics”, 10 th edition, Orient
Longman

NET REFERENCE:

 https://en.wikipedia.org
 https://www.nice.org.uk
 http://oas.biomedcentral.com

JOURNAL REFERENCE

http://www.researchgate.net
http://www.scribd.com
THEORY APPLICATION:

LINEAR REPRESENTATION OF RUBIN’S MODEL OF ATTAINMENT OF THE MATERNAL

ROLE
In 1967 Rubin described operations or means by which the maternal identity is incorporated into the

woman’s image of her

 Taking -on activities mimicry and role play

 Taking in activities - fantasy and introjections-projection-rejection

 Letting-go activities- grief work

Mimicry involves the replications of actions and behaviour carried out by role-model and learning

from a variety of sources about events in the future.

In Role play women act and roles that they will understand in the future. For e.g., they babysit for

friend’s children undertake feeding or child care activities. This role play may be something that actually

takes place or something that takes place in the imaginations.

Replication (taking -on activities) assists the woman, according to the model proposed by Rubin, to

understand how someone who is pregnant, or a new mother, behaves. Fantasy and the other operations of the

taking, in phase enable the woman to develop an understanding of how she is behaving.

In fantasy the woman imagines the future for herself for e.g., what the birth will be like, what the

baby will wear and the future relationships with other members of the family.

In grief work the woman review her past, roles and relinquishes those roles which are no longer

appropriate or possible, letting go takes place

Introjection projection- rejection is an active process in which the woman compares the available
models with her view of herself and makes active decision about adopting or rejecting particular models.

The maternal role identify described in this model comprises the achievement of the four task of
pregnancy which are accomplished by undertaking the operations or activities of mimicry, role play and so
on. Rubin suggests that this model can be imaginal as a sphere, with the maternal role identity at the centre,
surrounded by the operation. The operation of taking -on (mimicry and role play) precede the operations of
taking- in and letting-go and are thus depicted as the outer rings of the model.

KING GOAL ATTAINMENT THEORY

 The goal of nursing is to help individual maintain health so that they can function in their roles.

 The open system frame work consists of three interacting system personal, Interpersonal, Social.

 The attainment thereby addresses interaction, perception time, space communication, Transaction
role, stress and growth and development.

 Kings describes person as a social sentiment rational, perceiving controlling purposeful action
oriented time oriented being.
  Kings theory and the four concepts of the nursing metaparadigm

Person

Is a social sentient rational perceiving controlling purposeful action oriented time oriented being.

Has a right to self knowledge participation in decision that affects life and health and acceptance or
rejection of health care.

Has three fundamental health needs timely and useful health information care that prevents illness
and help when self care demands cannot be met.

Environment:

It is not specifically defined by King, although she uses the terms internal environment and external
environment in her open system approach. This could be interpreted from the general systems theory as an
open system with permeable boundaries that allow the exchange of matter energy and information.

Health

It is described by King as a dynamic state in the life cycle illness is viewed as interference in the
continuum of the life cycle.

It implies continuous adjustment to stress in the internal and external environment, using personal
resources to achieve optimal daily living.

Nursing:

1. Refers to describe nurse client interaction the focus of when is to help the individual maintain health
and function in an appropriate role.

2. Is viewed as an interpersonal process of action reaction interaction and transaction of Nurse’s

perceptions and those of the client influence the interaction.

3. Promotes, maintain and refers health and cares for a sick injured or dying client.

4. Is a service profession that meets a social need

5. Entails planning implementing and evaluation nursing care.

6. Uses a goal oriented approach in which individual with in a social system interact the nurse brings
special knowledge and skill to nursing process and client brings self knowledge and perceptions