Cord Prolapse Nursing Management

EXPLANATION

✔Correct answer:

Cover the prolapsed cord with sterile gauze soaked in sterile saline and place the patient in the Trendelenburg position. When an umbilical cord prolapse is discovered, the primary goal is to relieve pressure on the cord to prevent compromised blood flow and oxygenation to the fetus. The correct intervention involves covering the exposed cord with sterile gauze soaked in sterile saline to keep it moist and prevent drying, which can cause vasospasm and further compromise blood flow. Additionally, the patient should be positioned in the Trendelenburg position or knee-chest position, which uses gravity to help shift the fetus away from the prolapsed cord, thereby reducing pressure on it.

Umbilical cord prolapse occurs when the cord slips ahead of the presenting part of the fetus and exits through the cervix or vaginal opening. This can lead to cord compression between the fetus and the maternal pelvis, which restricts blood flow to the fetus and can result in hypoxia or even fetal death if not addressed promptly.

Think of the umbilical cord as a vital hose supplying water (oxygen) to a plant (the fetus). If the hose gets pinched (compressed), the water flow stops. By changing the position (Trendelenburg) and keeping the hose moist (using sterile saline), you help prevent further damage while waiting for the gardener (healthcare team) to fix the issue.

After performing the immediate interventions, Nurse Olivia should call for help and prepare for an emergency delivery, typically via cesarean section, as cord prolapse is a life-threatening emergency for the fetus.

• Place the patient in Trendelenburg or knee-chest position immediately to relieve pressure on the prolapsed cord.
• Cover the cord with sterile gauze soaked in sterile saline to maintain moisture and prevent vasospasm.
• Notify the healthcare team immediately to prepare for an emergency cesarean section.
• Continue to monitor the fetal heart rate and be prepared to assist with rapid delivery.

✘Incorrect answer options:

Gently reposition the prolapsed cord back into the vaginal canal. Attempting to reposition the cord back into the vaginal canal is incorrect and can cause further trauma or compression. The cord should be kept moist and protected, but not manipulated.

Position the mother in semi-Fowler's to enhance circulation. Semi-Fowler's position is not appropriate in this scenario as it does not effectively relieve pressure on the prolapsed cord. The Trendelenburg or knee-chest position is needed to use gravity to relieve cord compression.

Push the cord back into the vagina and position the patient in the Sim's position. As with the first option, pushing the cord back into the vagina is not recommended due to the risk of causing further damage or compression. Sim's position also does not adequately relieve pressure on the cord, making this option inappropriate.

EXPLANATION

✔Correct answer:

Stop the Pitocin infusion, reposition the patient, and administer oxygen. When hypertonic uterine contractions are identified, the priority is to reduce uterine activity to prevent fetal distress and uterine complications. Hypertonic contractions can decrease uteroplacental perfusion, leading to fetal hypoxia and potentially causing uterine rupture. The first step should be to stop the Pitocin infusion, as this will reduce the stimulation of the uterus. Repositioning the patient, often onto her left side, can improve blood flow to the uterus and placenta. Administering oxygen helps maximize maternal oxygenation, which can improve fetal oxygenation.

Steps of Intervention:

1. Stop the Pitocin infusion: This is the most critical immediate action to reduce the overstimulation of the uterus.
2. Reposition the patient: Typically to a side-lying position (preferably left side) to enhance uteroplacental blood flow.
3. Administer oxygen: This provides additional oxygen to the mother, which can help support fetal oxygenation during the period of reduced placental blood flow.

Think of the uterus like a balloon being filled with air (Pitocin). If it’s being filled too quickly, you need to stop adding air (stop Pitocin), adjust the balloon to relieve pressure (reposition the patient), and make sure there's enough fresh air around to keep things safe (administer oxygen).

After taking these initial actions, closely monitor the patient’s contractions and the fetal heart rate. If the contractions do not decrease or if fetal distress continues, notify the healthcare provider immediately for further interventions, such as the administration of a tocolytic medication.

• Stop the Pitocin infusion immediately to reduce uterine stimulation.
• Reposition the patient to optimize blood flow to the uterus and placenta.
• Administer oxygen to increase maternal oxygenation and enhance fetal oxygen delivery.
• Continuously monitor uterine contractions and fetal heart rate after these interventions.
• Notify the healthcare provider for further assessment and potential administration of a tocolytic if needed.

✘Incorrect answer options:

Increase the Pitocin infusion rate and notify the healthcare provider. Increasing the Pitocin infusion would exacerbate the hypertonic contractions, worsening the situation. This action is incorrect and could lead to severe complications such as fetal distress or uterine rupture.

Continue to monitor the patient and document the findings. While documentation is important, it is not the immediate priority when hypertonic uterine contractions are present. Immediate intervention is required to stop the Pitocin and manage the uterine hyperstimulation.

Administer a tocolytic medication and notify the healthcare provider. Administering a tocolytic, which relaxes the uterus, may be necessary if the contractions persist despite stopping the Pitocin. However, this is typically done after stopping the Pitocin and assessing the situation with the healthcare provider's guidance. It is not the first step.

EXPLANATION

✔Correct answer:

Uterine hyperstimulation. When labor is induced, particularly with medications like oxytocin (Pitocin), there is a risk of uterine hyperstimulation, also known as tachysystole. Uterine hyperstimulation is defined as excessively frequent contractions, usually more than five contractions in ten minutes, or contractions that last too long (greater than two minutes). This condition can reduce blood flow to the placenta, leading to fetal distress due to insufficient oxygenation. It is a serious complication that requires prompt intervention to prevent adverse outcomes for both the mother and the fetus.

Uterine hyperstimulation can result in decreased uteroplacental perfusion, leading to fetal hypoxia and acidosis. It may also cause uterine rupture, particularly in women with a history of cesarean section or uterine surgery. Immediate actions might include reducing or stopping the oxytocin infusion, administering a tocolytic (a medication to relax the uterus), and closely monitoring the fetal heart rate.

Imagine a balloon that is being inflated too quickly and with too much air. If you don’t slow down, the balloon could burst. Similarly, if contractions come too fast or are too strong, the uterus might not function properly, and the baby could be in danger.

Nurses should continuously monitor uterine activity and fetal heart rate during labor induction, being particularly alert for signs of uterine hyperstimulation.

• Monitor the frequency, duration, and intensity of contractions using a tocodynamometer and assess the fetal heart rate for signs of distress, such as late decelerations.
• If hyperstimulation is detected, stop the oxytocin infusion and notify the healthcare provider immediately.
• Administer oxygen to the mother and position her on her side to improve uteroplacental blood flow.
• Prepare for potential emergency interventions, such as the administration of a tocolytic agent or emergency cesarean delivery if fetal distress persists.

✘Incorrect answer options:

Intense, severe pain. While pain management is important during labor, intense pain alone is not as immediately concerning as uterine hyperstimulation. Pain can often be managed with analgesics or anesthesia, but it does not necessarily indicate a complication requiring urgent intervention unless associated with other signs of distress or abnormal labor progression.

Signs of low blood sugar. Hypoglycemia is not a typical concern during labor induction, though it can be a consideration in diabetic patients. The immediate concern during labor induction is more related to uterine and fetal complications rather than blood sugar levels.

Prolapse of the umbilical cord. Umbilical cord prolapse is a rare but serious emergency that can occur when the umbilical cord slips ahead of the fetus into the birth canal, leading to cord compression and compromised blood flow to the baby. However, it is not specifically associated with labor induction and is less likely than uterine hyperstimulation during this process.

EXPLANATION

✔Correct answer:

Notify the healthcare provider immediately. A fetal heart rate (FHR) of 100 beats per minute is below the normal range (110-160 bpm) and indicates fetal bradycardia. Fetal bradycardia can be a sign of fetal distress, especially in a post-term pregnancy where there is an increased risk of complications such as placental insufficiency or umbilical cord compression. Immediate notification of the healthcare provider is crucial so that appropriate interventions can be initiated, such as further assessment, intrauterine resuscitation measures, or preparing for an emergency delivery if necessary.

Fetal bradycardia may indicate that the fetus is not receiving adequate oxygen, which could be due to various factors such as umbilical cord compression, uteroplacental insufficiency, or maternal hypotension. The prolonged rupture of membranes also increases the risk of infection or cord prolapse, both of which can contribute to fetal distress.

Think of the fetal heart rate as a car's engine. If the engine starts running too slowly (fetal bradycardia), it could mean something is wrong under the hood (fetal distress). The sooner you check it out (notify the healthcare provider), the better the chances of preventing a breakdown (complications).

After notifying the healthcare provider, Nurse Emily should prepare to assist with any recommended interventions, such as intrauterine resuscitation or preparation for potential emergency delivery.

• Immediately notify the healthcare provider about the fetal bradycardia.
• Prepare to administer oxygen to the mother via face mask, reposition the mother, and increase intravenous fluids to improve fetal oxygenation if advised by the provider.
• Continue to monitor the fetal heart rate closely and document all findings and interventions.
• Be ready to assist with any emergency procedures, including possible cesarean delivery, if the fetal heart rate does not improve.

✘Incorrect answer options:

Reassess the fetal heart rate in 15 minutes. Delaying action in the presence of fetal bradycardia could lead to worsening fetal distress. Immediate intervention is required, and waiting 15 minutes without taking any action could compromise fetal well-being.

Administer oxygen to the mother via face mask. While administering oxygen is an appropriate intervention for fetal bradycardia, it should not be the first step before notifying the healthcare provider. Oxygen administration would typically be part of a broader intrauterine resuscitation strategy after consulting with the provider.

Encourage the mother to change positions. Repositioning the mother can help alleviate some causes of fetal distress, such as umbilical cord compression, but it is not the first action to take in this scenario. The healthcare provider needs to be notified immediately for further assessment and to direct the next steps in management.

EXPLANATION

✔Correct answer:

A sudden decrease in fetal heart rate after membrane rupture. A sudden decrease in the fetal heart rate, particularly after the rupture of membranes, is a critical sign that may indicate umbilical cord prolapse. When the membranes rupture, the cord can slip into the birth canal ahead of the presenting part of the fetus, leading to compression of the cord. This compression can reduce or cut off the blood flow and oxygen supply to the fetus, resulting in a sudden and significant drop in the fetal heart rate, often seen as variable decelerations or bradycardia on the fetal monitor.

The umbilical cord is the fetus's lifeline, supplying oxygenated blood from the placenta. If the cord prolapses, meaning it slips into the birth canal and is compressed by the fetus, it can lead to acute fetal hypoxia. The sudden onset of fetal bradycardia (a drop in the fetal heart rate below 110 beats per minute) after the membranes rupture is a hallmark sign of this condition, requiring immediate intervention to prevent fetal compromise.

Imagine a garden hose that provides water to a plant. If the hose gets pinched, the flow of water stops, and the plant starts to wither. Similarly, if the umbilical cord is compressed, the flow of oxygen to the fetus is reduced or cut off, leading to distress.

If a cord prolapse is suspected due to a sudden drop in the fetal heart rate, the nurse should immediately take actions to relieve cord compression, such as repositioning the patient into a knee-chest or Trendelenburg position, and prepare for an emergency cesarean section. Continuous fetal heart rate monitoring and prompt communication with the healthcare team are essential to ensure a positive outcome.

• Immediately reposition the patient to relieve pressure on the cord.
• Prepare the patient for an emergency cesarean section.
• Maintain continuous fetal heart rate monitoring to assess fetal well-being.
• Ensure prompt and clear communication with the obstetrician and the rest of the healthcare team.

✘Incorrect answer options:

An increase in maternal blood pressure. An increase in maternal blood pressure is not associated with umbilical cord prolapse. It is more commonly related to conditions like preeclampsia or stress but does not specifically indicate cord prolapse.

An irregular contraction pattern. While labor contractions can be irregular in many situations, this is not a specific indicator of cord prolapse. The primary concern in cord prolapse is the fetal heart rate, not the pattern of contractions.

Severe maternal back pain. Severe back pain during labor may be related to fetal positioning, such as an occiput posterior position, but it is not a sign of umbilical cord prolapse. The focus with cord prolapse is on the fetal heart rate and signs of fetal distress.

EXPLANATION

✔Correct answer:

Prolapse of the umbilical cord. In a breech presentation, where the baby's buttocks or feet are positioned to deliver first instead of the head, there is an increased risk of umbilical cord prolapse. This occurs when the umbilical cord slips down into the birth canal ahead of or alongside the presenting part of the fetus. Because the cord can become compressed between the baby and the maternal pelvis, it can lead to reduced or blocked blood flow and oxygen to the baby, which is an emergency situation requiring immediate intervention.

In a breech presentation, especially with incomplete or footling breech (where one or both feet are positioned to deliver first), there is more space for the cord to slip down past the presenting part. Once prolapsed, the umbilical cord can be compressed during contractions or as the fetus descends, leading to fetal hypoxia and potential emergency delivery via cesarean section if the situation cannot be resolved quickly.

Imagine trying to pull a heavy object (the baby) through a narrow door (the birth canal) while a rope (the umbilical cord) is hanging in front of it. If the object pushes the rope against the door frame, it cuts off the rope's ability to stretch, similar to how the cord can be compressed during a breech birth.

If Nurse Jenna suspects or identifies an umbilical cord prolapse, immediate actions should be taken to relieve pressure on the cord and expedite delivery to prevent fetal distress.

• Monitor fetal heart rate closely for signs of distress, such as variable decelerations, which could indicate cord compression.
• If cord prolapse is suspected or observed, immediately reposition the mother to relieve pressure on the cord and call for emergency assistance.
• Prepare for an emergency cesarean section if the situation does not resolve with repositioning and if there are signs of persistent fetal distress.

✘Incorrect answer options:

Placental abruption. While placental abruption is a serious complication, it is not specifically associated with breech presentation. It occurs when the placenta detaches prematurely from the uterus, leading to maternal hemorrhage and fetal distress, but it is a different concern than those directly related to breech births.

Caput succedaneum. Caput succedaneum refers to the swelling of a newborn’s scalp that appears as a lump or bump on their head shortly after delivery. It is usually harmless and not specifically associated with breech delivery, nor is it a critical concern like cord prolapse.

Abnormally high bilirubin levels. Elevated bilirubin levels are related to jaundice in the newborn and are typically managed postnatally. They are not directly related to the complications of a breech delivery and are not a concern during the actual birth process.

EXPLANATION

✔Correct answer:

A stoma that is protruding out from the abdominal surface. A stoma prolapse occurs when the bowel segment that forms the stoma extends outward, protruding more than usual from the abdominal surface. Normally, a stoma should protrude slightly, but in the case of a prolapse, it can extend several inches beyond the skin level. This condition is typically not painful, but it may cause discomfort, difficulty in fitting the stoma appliance, and an increased risk of complications such as stoma ischemia or trauma.

Stoma prolapse can occur due to factors such as increased intra-abdominal pressure, weakening of the abdominal wall, or improper surgical technique during stoma creation. This condition leads to the telescoping of the bowel through the stoma, resulting in a visibly elongated and protruding stoma.

Imagine a sock that’s supposed to be neatly folded over the edge of a drawer. If the sock slips, it starts hanging out of the drawer much more than it should, which is similar to how a stoma can prolapse and extend out further than normal.

Nurses should assess the stoma regularly and educate the patient on how to identify signs of complications like prolapse. Depending on the severity, a prolapsed stoma might be managed conservatively or require surgical intervention.

• Monitor the stoma for changes in color, size, and shape, particularly if it appears to be protruding more than usual.
• Instruct the patient on proper techniques for stoma care and how to fit the stoma appliance correctly, as prolapse can make this challenging.
• Advise the patient to report any changes in stoma appearance, discomfort, or difficulties with the stoma appliance, as these could indicate complications requiring medical attention.

✘Incorrect answer options:

A stoma that appears sunken and hidden. This description is characteristic of a retracted stoma, not a prolapsed stoma. A retracted stoma sits below the skin level, which can lead to issues with leakage and appliance fitting, but it does not protrude outward.

A stoma with a dark or bluish color. This is indicative of stoma ischemia or necrosis, where the blood supply to the stoma is compromised. This is a serious complication requiring urgent medical intervention, but it does not describe a prolapsed stoma.

A stoma that is narrow and flattened. A stoma that appears narrow and flattened could be due to stenosis, where the stoma's opening becomes constricted. This is different from a prolapsed stoma, which is characterized by excessive protrusion rather than narrowing.

EXPLANATION

✔Correct answer:

Prolapsed umbilical cord. In a breech presentation, the baby's buttocks or feet are positioned to deliver first, which increases the risk of umbilical cord prolapse. This occurs when the umbilical cord slips into the birth canal ahead of or alongside the presenting part of the fetus. If the cord becomes compressed during contractions or as the baby moves through the birth canal, it can restrict blood flow and oxygen to the baby, leading to fetal distress or even death if not managed promptly. Nurse Samantha should be vigilant for signs of cord prolapse, such as sudden fetal heart rate decelerations or seeing or feeling the cord at the vaginal opening.

Breech presentations, particularly footling breech (where one or both feet are positioned to deliver first), create more space for the umbilical cord to slip past the presenting part, leading to an increased risk of prolapse. Prolapse can result in cord compression between the fetus and the maternal pelvis, which compromises the baby's oxygen supply and requires immediate medical intervention.

Imagine trying to push a heavy object (the baby) through a doorway while a rope (the umbilical cord) dangles in front of it. If the object pushes against the rope, it pinches the rope, cutting off the flow (oxygen supply). The more space in the doorway (breech position), the higher the risk that the rope might slip down and get pinched.

If a prolapsed umbilical cord is suspected or observed, it is a medical emergency that requires immediate action to relieve pressure on the cord and ensure a safe delivery.

• Monitor fetal heart rate closely for any signs of distress, such as variable decelerations, which may indicate cord compression.
• Be prepared to reposition the mother in Trendelenburg or knee-chest position to help relieve pressure on the prolapsed cord if necessary.
• Call for immediate assistance and prepare for an emergency cesarean section if a prolapsed cord is confirmed.
• Educate the patient about the potential complications of a breech birth and the importance of close monitoring during labor.

✘Incorrect answer options:

Quickening. Quickening refers to the first movements of the fetus felt by the mother, typically occurring around 18-20 weeks of gestation. It is not a concern during labor, nor is it related to breech presentation or labor complications.

Ophthalmia neonatorum. Ophthalmia neonatorum is an eye infection that newborns can acquire during delivery, usually due to exposure to certain bacteria in the birth canal. While important, it is not related to breech presentation or a critical concern during labor itself.

Pica. Pica is the craving and consumption of non-food substances during pregnancy, such as dirt or clay. While it can be a concern during pregnancy, it is not related to breech presentation or labor complications.

EXPLANATION

✔Correct answer:

Position the patient in a knee-chest position on the bed. The first action Nurse Jessica should take when she notices an umbilical cord prolapse is to immediately relieve pressure on the cord to ensure blood flow and oxygen delivery to the fetus. Positioning the patient in a knee-chest position (or alternatively in Trendelenburg position) helps to shift the fetus away from the pelvic inlet, reducing compression on the prolapsed cord and improving fetal oxygenation.

Umbilical cord prolapse is an obstetric emergency where the umbilical cord slips ahead of the presenting part of the fetus during labor, potentially compressing the cord and cutting off the baby’s blood and oxygen supply. Immediate intervention is critical to prevent fetal hypoxia and distress. The knee-chest position or Trendelenburg position helps to alleviate pressure on the cord by using gravity to move the fetus away from the pelvis.

Think of a garden hose that is bent and pinched under a heavy object, blocking water flow. By lifting the object (changing the patient’s position), you relieve the pressure on the hose (umbilical cord), allowing water (blood and oxygen) to flow freely again.

After positioning the patient, the nurse should maintain manual elevation of the presenting part off the cord if possible, monitor the fetal heart rate closely, and prepare the patient for an emergency delivery, often a cesarean section. The nurse should also stay calm and quickly communicate with the healthcare team to ensure prompt action.

• Continuously monitor the fetal heart rate to assess for any signs of fetal distress.
• Prepare the mother for an emergency cesarean section if indicated.
• Ensure that the healthcare team, including the physician, is immediately informed and involved.
• If the cord is exposed, cover it with a sterile saline-soaked dressing to prevent it from drying out, but only after positioning the patient.

✘Incorrect answer options:

Start monitoring the mother’s vital signs and fetal heart rate. While monitoring the fetal heart rate is essential, it is not the first action. The primary focus should be on relieving pressure on the prolapsed cord to prevent fetal hypoxia before initiating any monitoring.

Inform the physician and get the patient ready for delivery. Although it is crucial to inform the physician and prepare for delivery, the immediate priority is to relieve the pressure on the umbilical cord. Delaying this action could lead to irreversible fetal distress.

Cover the exposed cord with a sterile warm saline dressing. Covering the cord with a sterile saline dressing is important if the cord is exposed, but it is not the first action to take. The priority should be on positioning the patient to relieve pressure on the cord before taking steps to protect the cord.

EXPLANATION

✔Correct answer:

Position the patient in Trendelenburg's position. The first action Nurse Ava should take when noticing an umbilical cord prolapse is to immediately relieve pressure on the cord to prevent compromised blood flow to the fetus. Positioning the patient in Trendelenburg’s position (where the patient is laid flat on their back with the feet elevated higher than the head) or in the knee-chest position is crucial as it uses gravity to shift the fetus away from the pelvis, thus reducing pressure on the prolapsed cord. This is an emergency situation, and the primary goal is to maintain oxygenation to the fetus by ensuring that the umbilical cord is not compressed.

Umbilical cord prolapse occurs when the umbilical cord slips ahead of the presenting part of the fetus and protrudes through the cervix or into the vagina. If the cord is compressed, it can restrict blood flow and oxygen to the fetus, leading to hypoxia or even fetal death if not managed immediately.

Imagine a garden hose (umbilical cord) providing water (oxygen) to a plant (the fetus). If the hose gets pinched (cord compression), the water flow stops. Elevating the hose (Trendelenburg’s position) helps to keep it from getting pinched, ensuring the plant still gets water.

After repositioning the patient, immediate actions should follow, including notifying the healthcare team and preparing for an emergency delivery, usually via cesarean section.

• Position the patient to relieve pressure on the umbilical cord immediately using Trendelenburg’s or knee-chest position.
• Manually lifting the presenting part off the cord with a sterile gloved hand may be necessary if the position change is not enough to alleviate compression.
• Notify the delivery team immediately for urgent intervention and prepare for an emergency cesarean delivery.
• Administer oxygen to the mother to maximize fetal oxygenation.
• Maintain manual pressure to relieve cord compression while awaiting surgical intervention if needed.

✘Incorrect answer options:

Notify the delivery room staff for immediate transport. While notifying the delivery team is crucial, it is not the first action. Relieving pressure on the cord is the immediate priority to prevent fetal hypoxia.

Carefully attempt to reposition the cord back into the vagina. Repositioning the cord manually back into the vagina is not advised, as it could cause additional trauma or worsen cord compression. The priority is to relieve pressure on the cord through maternal repositioning and manual elevation of the presenting part if necessary.

Quickly locate a phone to urgently page the physician. Again, while notifying the physician is essential, it is secondary to the immediate need to relieve pressure on the umbilical cord by repositioning the patient. Immediate action to relieve cord compression is the top priority.