Cordocentesis: Diagnosing Fetal Concerns

Cordocentesis

• Performed to diagnose fetal malformations, infection (e.g. toxoplasmosis, rubella), fetal platelet count, fetal anemia, and isoimmunization
• Potential side effects include blood loss, infection, drop in fetal heart rate, premature rupture of membranes, fever, chills, and leaking of amniotic fluid

Malposition

• A term used to describe a fetus that is rotated so that it is in the occiput posterior or occiput transverse positions
• Types: occipitoposterior positions, occipitotransverse positions
• Factors: multipara, lax abdominal wall

Occipitoposterior Positions

• The most common malposition
• The head initially engages normally but then the occiput rotates posteriorly rather than anteriorly
• Related factors: flat sacrum, android, anthropoid or contracted pelvis, poorly flexed head, weak uterine contractions, epidural analgesia

Nursing Management

• Close maternal and fetal monitoring
• Counterpressure on the sacrum
• Applying hot or cold
• Lying on side opposite the fetal back to help fetus rotate
• Woman should void every 2 hours and receive adequate fluid and IV glucose solution
• May need to instruct not to push before full dilatation

Occipitotransverse Position

• It is the incomplete rotation of OP to OA results in the fetal head being in a horizontal or transverse position
• Management: manual rotation with Keillands forcep or delivery using vacuum extraction, immediate CS if failure to deliver through forceps
• Abdominal examination: the lower part of the abdomen is flattened, fetal limbs are palpable anteriorly, and the fetal flank
• Vaginal examination: the posterior fontanelle is toward the sacrum and the anterior fontanelle may be easily felt if the head is deflexed
• Maternal risks: prolonged labor, potential for operative delivery, extension of episiotomy, 3rd or 4th degree laceration of the perineum
• Maternal symptoms: intense back pain in labor, dysfunctional labor pattern, prolonged active phase, secondary arrest of dilatation, arrest of descent

Nursing Management

• Encourage the mother to lie on her side from the fetal back, which may help with rotation
• Pelvic-rocking knee-chest position may help and facilitate rotation
• Apply sacral counter-pressure with heel of hand to relieve back pain
• Continue support and encouragement: Keep client and family informed of progress
• Praise client's efforts to maintain control
• Monitor FHT appropriately
• Be prepared for childbirth emergencies such as C-section, forceps-assisted delivery, and neonatal-resuscitation

Management

• If there are signs of obstruction or the fetal heart rate is abnormal at any stage, deliver by caesarean section
• If the cervix is not fully dilated and there are no signs of obstruction, augment labor with oxytocin
• If the cervix is fully dilated but there is no descent in the expulsive phase, assess for signs of obstruction
• If the cervix is fully dilated and if the leading bony edge of the head is above -2 station, perform caesarean section
• If the leading bony edge of the head is between 0 station and -2 station, deliver by vacuum extraction and symphysiotomy
• If the operator is not proficient in symphysiotomy, perform caesarean section
• If the bony edge of the fetal head is at 0 station, deliver by vacuum extraction or forceps

Vertex Presentation

• The vertex presentation describes the orientation a fetus should be in for a safe vaginal delivery
• Types: breech presentation
• Breech presentation: it means that either the buttocks or the feet are the first body parts that will contact the cervix
• Most common malpresentation, occurs in approximately 3% of the births
• More common in premature labor
• Breech presentations can be difficult births, with the presenting point influencing the degree of difficulty
• Approx 1/3 are diagnosed during labor

Types of Breech Presentation

• Complete (Flexed) Breech Presentation: the baby's hips and knees are flexed so that the baby is sitting crosslegged, with feet beside the bottom
• Footling Breech Presentation: one or both feet come first, with the bottom at a higher position, rare at term but relatively common with premature fetuses