Cord Prolapse: Types, Etiology, Pathophysiology

Cord Prolapse

• Cord prolapse involves the umbilical cord descending into the vagina ahead of the fetus, which can compress the cord between the presenting part and the pelvis.
• It is an emergency that usually requires immediate delivery.
• Cord prolapse occurs in 1 of 200 pregnancies.

Etiology of Cord Prolapse

• Prematurity
• Rupture of membranes with the fetal presenting part not engaged
• Shoulder or footling breech presentations
• Rupture of the amniotic membranes with fluid rush carrying the cord

Types of Umbilical Cord Prolapse

• Occult cord prolapse: The cord slips alongside the baby, but not before.
• Overt cord prolapse: The cord slips into the cervix and vagina ahead of the baby.

Pathophysiology of Cord Prolapse

• Compression of the cord can cut off fetoplacental perfusion.
• The umbilical cord will protrude from the vagina
• The umbilical cord can be palpated in the vaginal canal or cervix.
• Cord compression between the presenting part and bony prominence may cause fetal distress

Medical Management of Cord Prolapse

• Cover the exterior cord with sterile saline gauze to prevent drying and minimize infection.
• Call for help
• Organize delivery
• Relieve pressure on the cord
• Delivery of fetus

Nursing Management of Cord Prolapse

• Delivery of the fetus as soon as possible.
• Frequently assess laboring clients, especially if the fetus is preterm or small for gestational age, the presenting part is non-engaged, or the membranes are ruptured

FHR Evaluation for Potential Cord Prolapse

• Periodically evaluate FHR after membrane rupture (spontaneous or surgical), and then again in 5–10 minutes.
• Notify the physician and prepare for an emergency cesarean birth if a prolapsed cord is identified. If the client is fully dilated, vaginal delivery may be the quickest route, assist with delivery.
• Lower the head of the bed and elevate the client's hips on a pillow or place client in the knee-chest position to relieve pressure on the cord
• Assess cord pulsations constantly
• Wrap the prolapsed cord gently with gauze soaked in sterile normal saline solution.

Fetal Distress

• Fetal distress is fetal hypoxia that can cause fetal death.
• Depletion of O2 and the accumulation of CO2 leads to hypoxia and acidosis in the intrauterine life.

Maternal Etiology of Fetal Distress

• Poor placental perfusion
• Hypovolemia
• Hypotension
• Myometrial hypertonus
• Prolonged labor
• Excess oxytocin

Fetal Etiology of Fetal Distress

• Cord compression,
• Oligohydramnios
• Entanglement
• Prolapse
• Pre-existing hypoxia or growth retardation
• Infection
• Cardiac problems

Signs and Symptoms of Fetal Distress

• Increased or decreased fetal heart rate (tachycardia and bradycardia), particularly during or after a contraction.
• Decreased variability in the fetal heart rate
• Abnormal fetal heart rate (< 120 or > 160 bpm)
• Amniotic fluid contaminated by meconium
• Decreased fetal movement felt by the mother

Fetal Distress Management

• Let the mother assume a left side lying position.
• Administer oxygen by mask
• Perform a vaginal examination to check for a prolapsed cord

Nursing Management of Fetal Distress

• Administer O2 by nonrebreather mask.
• Carry out doctor's orders for pre-operative routines.
• Monitor fetal heart tones (continuous fetal monitoring).
• Vaginal examination to check for prolapsed cord, rule out imminent vaginal delivery.
• Initiate pre-operative routines.

Cephalopelvic Disproportion

• Cephalopelvic disproportion implies the size is not correct between the head of the baby and the mother's pelvis.
• Complications occur if fetal head is too large to pass through the mother's pelvis or birth canal.
• Frequent diagnosis for cesarean sections.

Diagnosis of Cephalopelvic Disproportion

• Radiologic pelvimetry X-rays or or CT scans in different angles and pelvic diameters are measured
• Ultrasound can estimate baby's size.

Clinical Manifestations of Cephalopelvic Disproportion

• Irregular uterine contractions
• Ineffective uterine contractions strength and duration

Nursing Interventions for Cephalopelvic Disproportion

• Monitor heart sounds and uterine contractions continuously during a possible trial labor while urging the woman to void every 2 hours.
• Assess FHR carefully
• Establish a therapeutic relationship, conveying empathy and unconditional positive regard
• Instruct in methods to conserve energy
• Gently massage bony prominences and change the position on bed in a regular schedule
• Convey confidence in the client's ability to cope with the current situation
• Optimize uterine activity for dysfunctional patterns using palpation and electronic monitors
• Prevent unnecessary fatigue, check fatigue level and ability to cope with pain
• Prevent complications for the client and infant
• Assess urinary bladder, catheterize if needed
• Assess maternal vital signs, temperature, pulse, respiratory rates, and blood pressure
• Maternal urine should be checked for acetone (indicating dehydration and exhaustion)
• Assess the condition of the fetus by monitoring FHR, fetal activity, and color of amniotic fluid
• Provide physical and emotional support.
• Promote relaxation through bathing and keeping the client and the bed clean, back rubs, frequent position changes (side-lying position), walking (if indicated), and a quiet environment.
• Coach the client in breathing and relaxation techniques
• Provide client and family education.

Shoulder Dystocia

• Shoulder dystocia involves the anterior shoulder of the baby being unable to pass under the maternal pubic arch.

Etiology of Shoulder Dystocia

• Advanced maternal age
• Maternal diabetes or obesity
• Large baby (macrosomia)
• Past-due pregnancy
• Multiparity

Pathophysiology of Shoulder Dystocia

• The fetal shoulders align perpendicular to the pubis instead of at an angle, causing the shoulder to become stuck under the pubic arch.

Assessment Findings in Shoulder Dystocia

• The birth process is unnecessarily prolonged.
• The fetal head retracts against the mother's perineum as soon as the head is delivered.
  • Known as the "turtle sign."
• External rotation does not occur.

Nursing Management of Shoulder Dystocia

• Place the client in the McRobert's Maneuver
  • Thighs pulled up against the abdomen with hips abducted
  • The woman flexes her thighs sharply against her abdomen, which straightens the pelvic curve.
  • A supported squat has a similar effect and adds gravity to her pushing efforts.
• Apply suprapubic pressure
  • An assistant pushes the fetal anterior shoulder downward to displace it from above the mother's symphysis pubis.
  • Fundal pressure should not will push the anterior shoulder more firmly up against the symphysis.

Uterine Rupture

• Uterine rupture is a spontaneous or traumatic tear of the uterus.

Etiology of Uterine Rupture

• Uterine sounds or curettes used in abortion can cause injury.
• Obstetric intervention, like excessive fundal pressure, forceps delivery, bearing down, tumultuous labor, and fetal shoulder dystocia.
• Spontaneous uterine rupture is most likely to occur after previous uterine surgery, grand multiparity combined with the use of oxytocic agents, cephalopelvic disproportion, malpresentation, or hydrocephalus.

Types of Uterine Rupture

• Complete rupture: A tear that goes through all three layers of the uterine wall is very serious and requires immediate treatment.
• Incomplete rupture: The tear doesn't go through all three layers of your uterine wall.

Uterine Rupture Assessment

• Varies from mild to severe depending on site/extend of the rupture degree of extrusion of the uterine contents, and intraperitoneal evidence or absence of spilled amniotic fluid and blood
  • Sudden, sharp abdominal pain during contractions
  • Abdominal tenderness
  • Contractions stop
  • Bleeding into the abdominal cavity, or sometimes into the vagina
  • Fetus easily palpated, fetal heart tones ceases
  • Signs of shock
    • Rapid, weak pulse
    • Cold, clammy skin
    • Pallor
    • Air hunger flaring nostrils
• Incomplete Rapture is the same as complete except this develops over a few hours

Nursing Management of Uterine Rupture

• Assess possibility of uterine rupture.
• Assess uterine contour and palpable fetal part
• Monitor maternal labor pattern for hypertonicity or signs of weakening uterine muscle in the presence of predisposing factors.
• If a rupture is suspected, notify the doctor.
• If possible uterine rupture, vaginal delivery is generally not attempted.

Uterine Inversion

• Uterine Inversion is when the uterus turns completely or partially inside out following delivery of the placenta or in the immediate postpartum period.

Types of Uterine Inversion

• Forced inversion: Caused by pulling on the chord or manually expressing the placenta/clots from the uterus
• Spontaneous inversion: Increased abdominal pressure from bearing down, coughing, or abdominal muscle contraction

Predisposing Factors Contributing to Uterine Inversion

• Straining after delivery of the placenta.
• Kneading of the fundus.
• Manual extraction of the placenta.
• Rapid delivery with gestation.
• Rapid release of excessive amniotic fluid

Pathophysiology of Uterine Inversion

• The inverted uterus is not able to restore the normal position, thus leading to increased bleeding and infection.

Assessment of Possible Uterine Inversion

• Excruciating pelvic pain with fullness extending into the vagina
• Extrusion of the inner uterine lining into the vagina
• Vaginal bleeding and signs of hypovolemia

Nursing Management of Uterine Inversion

• Recognize and identify and resolution of uterine is key.
• If manual reinversion is not successful, prepare the client and family for possible general anesthesia and surgery.
• Take steps to prevent or limit hypovolemic shock.
• Insert a large-gauge IV catheter for fluid replacement.
• Measure and record maternal vital signs every 5 to 15 minutes to establish a baseline and document change.
• A fibrinogen level should be drawn to determine blood clot risk.
• Prepare for anesthesia or CPR if needed

Precipitate Labor

• Precipitate labor and birth is rapid, less than 3 hours
• Caused by reduced resistance of uterus/ cervix to passage of fetus or intense uterine contractions

Potential Precipitate Hazards

• Perineal laceration and postpartum hemorrhage.
• Infant risks: Hypoxia and intracranial hemorrhage

Assessment of Precipitate Labor

• Rapid cervical dilation
• History of rapid labor
• Rapid uterine contractions with decreased relaxation between contractions

Management of Percipitate Labor

• Monitor vital signs.
• Promote fetal oxygenation, stop pitocin induction, administer 02
• IV fluids

Preterm Labor

• Preterm labor is when labor begins after 20 weeks' gestation and before 37 weeks' gestation.
• Regular contractions documented at least 4 in 20 minutes or 8 in 60 minutes with improvement of the cervical score in the form of effacement of 80% or more and cervical dilatation >1cm.

Management of Pre Term Labor

• Medical treatment focuses on preventing premature delivery.
• Conservative treatment
  • bed rest in left lateral position
  • Hydration with IV therapy and fetal and uterine contraction monitoring
  • Give tocolytic's if contractions do not stop
• Possible Complications: PROM, Preeclampsia, Hydramnios, Placenta Previa, Abruptio Placentae, Incompetent Cervix, Trauma, Uterine structural anomalies, Multiple gestation, Intrauterine infection (chorioamnionitis), Congenital adrenal hyperplasia, Fetal death or stress (physical and emotional), urinary tract infections, and dehydration.

Post Term Labor

• is pregnancy that extends beyond 42 weeks' gestation or 2 weeks' beyond your expected due date.

Etiology Post Term Labor

• Unknown
• Possibly insufficient estrogen

Fetal Risks with Post Term Labor

• Less amniotic fluid, can lead to cord compression
• Decreased placenta and nutritional transport, fetus may become compromised
• Hypoglycemia or asphyxia
• Increased size and hardening of skull.

Assessment for Post Term Labor

• Weight loss and decreased uterine size.
• Excessive size
• Fluid test

Management of Post Term Labor

• Assess fetus to identify complications, monitor fetal status, assist with labor and prepare for difficult delivery

Amniotomy

• Artificial rupture of this membrane.

Labor Induction

• Deliberate initiation of labor before can be.

Prostaglandin

• Suppository is inserted every 2 hoursx3, make sure to keep it cold but bring to room temperature prior to inserting. Have patient remain in dorsal recumbent position for 15-30 minutes
• May have an infusion of oxytocin 8-12 hours after insertion

Amniotic Fluid Embolism

• Escape of amniotic fluid into mom

Possible symptoms in Fetus/Neonatal

• Can cause tachypnea, hemorrhage, chest pain

Predisposing factors

• Possible factors intrauterine death, oxy augmentation, and high parity

Disseminated Intravascular Coagulation

• Thrombia production in body leads to hemorrage

Episotomy Types of incissions

• Mediolateral and median incision

Factors for Median Incision

• Low risk for anal muscle

First Degree Laceration

• Involves vaginia mucosa and skin of perineum to fourchette

Forceps Delivery

• A tool that allows the child to be rotated for delivery through birthing canal or a procedure done

Abominal incisions for CS

• Classical verticle incission in the cases fetus has reached floor with sagutal suture. Is rapid and easy to preform permits easir access Is higher blood loss due to rupture Has risk of adhesions Can lead to Transerve low and segment

Factors for CS

• Failure to progress, prior cesction, fetus is breech and multiple fetuses. Fetus distress