NUR241 Module D4: Childbirth Emergencies

occurs when the umbilical cord is displaced, preceding the presenting part of the fetus or protruding through the cervix

results in cord compression and compromised fetal circulation

prolapsed cord

rare, but life-threatening obstetric injury that involves a tear through the uterine wall, peritoneal cavity and/or broad ligament where internal bleeding is present

complete uterine rupture

goes through all three layers of the uterine wall

rare, but life-threatening obstetric injury that occurs with dehiscence at the site of a prior scar (c/s or other surgical intervention) in the uterus, where internal bleeding may not be present

incomplete uterine rupture

does not go through all three layers of the uterine wall

condition that occurs when the placenta separates from the uterine wall prior to birth

abruptio placentae

infiltration of amniotic fluid into maternal circulation

anaphylactoid syndrome

aka: amniotic fluid embolism

what might put a client at risk for a prolapsed cord

abnormal fetal presentation (anything other than vertex/head down)

transverse lie (fetal position)

unengaged presenting part

hydramnios or polyhydroamnios

ROM

SGA

unusually long cord

multifetal pregnancy

what do most of the risk factors for a prolapsed cord have in common in terms of mechanism

they involve abnormal positioning of the fetus or issues with amniotic fluid volume

remember, one of the functions of amniotic fluid is to float the cord and prevent compression

expected findings in a client with a prolapsed cord

FHR monitor shows variable or prolonged decels

excessive fetal activity followed by cessation of movement (suggests severe fetal hypoxia)

visualization or palpation of the umbilical cord protruding through the introitus (vaginal opening)

reports of something coming through the vagina

t or f

if you suspect or have visual confirmation of cord prolapsed in a client, you should not leave them alone

true

call for assistance immediately

how can you reposition a client with a prolapsed cord in order to relieve pressure on the cord

reposition the client in knee-chest, Trendelenburg, or a modified lateral semi-prone recumbent position with a rolled towel under the right or left hip

if a client has a prolapsed cord that is exposed, what should you do

apply a warm, sterile, saline-soaked towel to the visible cord to maintain blood flow

the saline soaked towel prevents the cord from drying out

if a client has a prolapsed cord, how can you relieve pressure on the cord from the fetus

using a sterile-gloved hand, insert two fingers into the vagina and apply finger pressure on either side cord to the fetal presenting part to elevate it off of the cord

your fingers should be straddling the cord, DO NOT HANDLE THE CORD

nursing interventions for a prolapsed cord

notify the provider

call for assistance immediately (do not leave the client)

using a sterile-gloved hand, insert two fingers into the vagina and apply finger pressure on either side cord to the fetal presenting part to elevate it off of the cord

your fingers should be straddling the cord, DO NOT HANDLE THE CORD

reposition the client in knee-chest, Trendelenburg, or a modified lateral semi-prone recumbent position with a rolled towel under the right or left hip

CONTINUOUS EFM for variable decelerations, indicating fetal asphyxia or hypoxia

administer oxygen at 8-10L/min via a non-rebreather mask to improve fetal oxygenation

initiate IV access and administer a fluid bolus

prepare for immediate vaginal delivery if cervix is fully dilated; c/s if not fully dilated

maintain communication and educate the client and her partner

what are risk factors for uterine rupture

congenital uterine abnormality

uterine trauma due to accident or surgery (ex: previous c/s)

overdistention of uterus: LGA infant, polyhydramnios, multifetal gestation

tachysystole of the uterus (spontaneous/oxytocin induced)

external or fetal version to correct fetal malposition

forceps-assisted birth

what is a tale-tell sign of a uterine rupture

2 hump appearance

how might a client describe their symptoms when experiencing a ruptured uterus

they may report a sensation of "ripping" or "tearing" or sharp pain

abdominal pain/uterine tenderness

expected findings in a client with a uterine rupture

client may report a sensation of "ripping" or "tearing" or sharp pain

abdominal pain/uterine tenderness

non-reassuring FHR with signs of fetal distress (bradycardia, variable/late decels with absent/minimal varibility)

change in uterine shape and palpable fetal parts

"2 humps"

cessation of contractions and loss of fetal station

manifestations of hypovolemic shock (tachycardia, hypotension, clammy skin, anxiety, etc)

clients who are experiencing a ruptured uterus should be prepared for

an immediate cesarean birth

this can involve a laparotomy and/or a hysterectomy

inform client and their partner about treatment

nursing actions for a client with a uterine rupture

administer IV fluids

administer oxygen

administer blood products, if prescribed (this can include Rhogam)

prepare client for c/s

inform the client and their partner about treatment

risk factors for abruptio placentae

maternal HTN (chronic or gestational)

blunt external trauma (MVA, DV)

cocaine use

cigarette smoke

previous incidents of abruptio placentae

multifetal pregnancy

multi-parity

what is the biggest concern with placental abruption

hemorrhage

significant cause of maternal and fetal morbidity and mortality

expected findings of abruptio placentae

sudden intense-localized pain with dark red vaginal bleeding

area of uterine tenderness can be "board-like"

contractions with hypertonicity

fetal distress

clinical findings of hypovolemic shock

other than hemorrhage/hypovolemic shock, what are potential complications of abruptio placentae

fetal asphyxia

prematurity

what labs are run in clients with abruptio placentae

h/h

coagulation factors

clotting defects

blood type and cross

how is the placenta assessed in clients with abruptio placentae

ultrasound

how is abruptio placentae treated

immediate c/s

IV fluids and blood products (if indicated)

monitor for s/sx of DIC

emotional support for client and partner

pathophysiology of anaphylactoid syndrome

rupture in amniotic sac or maternal uterine veins + high uterine pressure

infiltration of amniotic fluid into maternal circulation

amniotic fluid travels to and obstructs pulmonary vessels

respiratory distress and circulatory collapse

when does anaphylactoid syndrome occur

can occur during labor, birth, or within 30 minutes following birth

what complication can occur with anaphylactoid syndrome

serious coagulation problems (like DIC) can occur

risk factors for anaphylactoid syndrome

placenta previa or abruption

preeclampsia/eclampsia

hypertensive disorders

oxytocin administration

diabetes

c/s

forceps-assisted birth

uterine rupture

cervical laceration

meconium stained fluid

when suffering from anaphylactoid syndrome what will the client complain of

sudden chest pain and/or shortness of breath

what are physical assessment findings in anaphylactoid syndrome

restlessness

cyanosis

dyspnea

pulmonary edema

respiratory arrest

nursing interventions for anaphylactoid syndrome

administer oxygen 8-10L/min via non0rebreather mask

assist with intubation and mechanical ventilation as indicated

perform CPR if necessary

administer IV fluids

position client on one side with pelvis tilted at a 30-degree angle to displace the uterus

insert foley and measure UOP

monitor maternal and fetal status

prepare for emergency c/s if baby hasn't been delivered

medications administered for anaphylactoid syndrome

atropine

ondansetron

ketorolac

remember: A-O-K