Day 3: Birth Emergencies and Preterm Labor

What is a prolapsed umbilical cord?

Cord exits cervix before any fetal part

What are the maternal and fetal risk factors for a prolapsed umbilical cord?

Maternal: polyhydramnios, PROM (premature rupture of membrane).

Fetal: IUGR (intrauterine growth restriction), malpresentation, SGA (baby is small so cord can slip by), multiple gestations (space is bigger for the cord to slip out).

What things that healthcare professionals do can lead to risks for a prolapsed umbilical cord?

• Amniotomy (breaks water)

• External cephalic version (turn the fetus into a different position from outside).

• IUPC (intrauterine pressure catheter) placement

• Cervical ripening balloon placement

What are 2-3 comorbidities for developing prolapsed umbilical cord?

Maternal diabetes

Infection

Fetal anomalies affecting amniotic fluid volume

Incidence of prolapsed umbilical cord?

1-6 in 1,000

Info card

Most occur shortly after membrane rupture ​

Historically high mortality, now reduced with cesarean​

Complications: Cerebral palsy, encephalopathy (brain damage) from hypoxia ​​

How does a prolapsed umbilical cord present on a fetal heart monitor / what things would you see?

Prolonged decel (3 mins or longer) HR slows down for periods

Bradycardia (HR in the 90s about)

Recurrent variable decels: (every few minutes) A W or V shape.

What are the treatments for a prolapsed umbilical cord? Think FRAMIRO.

F: Fetal presenting part elevated with a gloved hand

R: Rapid response team notified

A: apply O2 if needed

M: Monitor fetal HR

I: insert IV and indwelling cath.

R: Reposition client

O: Oxytocin DISCONTINUED

What IV for baby/ what is usually the smallest you can go to give blood?

18-20g for baby

20 is usually smallest you can go

What is placental abruption / abruptio placentae? What are the 2 types? Is this concerning?

placental wall separates from uterine wall.

2 Types: Partial or total

This can happen before or during birth.

This is very concerning to the client and the fetus.

What are some risk factors for a placental abruption?

• Trauma

• Change in uterine pressure

• Infection

• Short umbilical cord

• Drugs that cause HTN and HTN itself

• Increased maternal age

• Gestational DM

• IVP

What are some symptoms of placental abruption? On test:

• sharp abdominal pain

• vaginal bleeding: can be concealed or overt

• Board-like abdomen

• Uterine tenderness

• Hypovolemia (low fluid in body) signs like hypotension and tachycardia.

• Fetal distress: Prolonged bradycardia, late decelerations.

What are some lab interventions for a placental abruption?

CBC

Clotting studies

BUN/creatinine

Kleihauer-Betke test

What is the Kleihauer-Betke test (ON TEST)?

This is a lab procedure used to detect and quantify fetal RBC’s in the mother’s blood / if their blood has mixed.

How do you treat a placental abruption?

Emergency C-section for a severe abruption

Management for a marginal abruption if mom and baby are stable.

Can maternal psychologic stressors lead to more likelihood of abruptions?

Yes, it increases risk.

What is a uterine rupture?

3 layers of uterus tear

What is a threatened rupture?

Dehiscence - thinning of the uterine wall.

What percent of births result in a uterine rupture?

Less than 1%

What are some things that may lead to uterine rupture?

Gestation diabetes which can lead to macrosomia and polyhydramnios

Uterine anomalies like fibroids.

Previous C sections.

What are some S/S of uterine rupture?

Uterine atony - loss of uterine contractions

Acute onset of abdominal pain or tenderness with palpation (ON TEST)

Referred shoulder or chest pain

Nausea, dizziness or anxiety

Sudden change of shape of uterus

Loss of fetal station (ability to feel where it’s at)

Hypotension and tachycardia

What are some interventions for uterine rupture?

• Reposition client to lateral (side) position

• Immediate C-section and possible hysterectomy

• STOP oxytocin

• Give O2

• Initiate 2 IV lines (20 G) - blood transfusion for hemorrhage

• Indwelling Cath

• Collect blood and send to lab for type and cross match to establish treatment

What should you remind someone of if they have had a uterine rupture with future pregnancies?

• They will be monitored closely

• Wait 18 months to get pregnant

• May be another cesarian

What is ‘turtle sign’? What does it mean?

Baby head comes out and bobs back in. It means it is stuck.

• shoulder dystocia

• LGA due to maternal diabetes

• Male (usually bigger)

• Epidural during labor

• Prolonged 2nd stage (pushing stage)

What are some shoulder dystocia interventions / what does CAMPEER stand for?

C - call for help

A - Apply suprapubic pressure

M - movement of fetal arm across the head to dislodge should attempted by provider

P - Position the client onto hands and knees

E - Episiotomy

E - Elevate legs to knee-chest position

R - Rotation of the fetus manually by provider

What are some maternal and neonatal injuries from shoulder dystocia?

Maternal:

• perineal lacerations

• PPH

• Uterine rupture

• Bladder laceration

• Nerve damage

Baby:

• Brachial plexus injury

• Facial nerve injury

• Risk of asphyxia and potential death

When is preterm labor? When is late preterm and when is early preterm?

Preterm: before 37 weeks

Early: 34 weeks and below

Late: 34-37 weeks

What are some risk factors for preterm birth?

• Infection

• Stress and depression

• Gestational DM

• HTN

• Multiples

• Low BMI

• Age over 35

• Partner violence

• Substance abuse and many more

What are these different tests and what are they used for?

• NST​ - nonstress test

• BPP / US​ - ultrasound

• fetal fibronectin (fFN)​ (ON TEST). What do the 2 possible results mean?

NST: Monitors baby HR and movement.

US: Checks movement, muscle tone, breathing movements, and amniotic fluid.

Fetal fibronectin: Swab and sent to lab. A positive test doesn’t give a lot of info. A negative test means likely no labor in the next 2 weeks.

What 2 things can you do to treat/prevent preterm birth?

Tocolysis - meds to stop uterus from contracting / slow labor.

Cerclage

What is cerclage? When is it usually placed and taken out by?

Stitch in the cervix to close it.

It is placed around 12-24 weeks.

It must be taken out at 36 weeks.

Tocolysis meds:

Terbutaline: Route and indication. 3 side effects (ON TEST):

subQ and IV

Stops contractions

Side effects:

• Tachycardia

• Severe anxiety

• Pulmonary edema

Tocolysis meds:

Nifedipine: Route, type of drug, indication.

Oral

Calcium channel blocker

Blocks ability for uterus to contract (needs calcium to do so)

Tocolysis meds:

Mag sulfate. Given often for preterm labor? Indication (2). What does this drug allow the administration of and why is this second one given?

No

Calms smooth muscle down.

Prevents baby from getting cerebral palsy (neural protection)

Allows administration of corticosteroids to mature and increase surfactant in baby’s lungs.

What route for corticosteroids? What are 2 brand names for it?

IM

Betamethasone or dexamethasone.

What happens if a close to term mom experiences PROM?

They will likely just induce her

What would you do for PROM to keep the baby from being delivered.

Tocolysis, corticosteroids (to prep baby’s lungs just in case), mag sulfate for neuroprotection.

What antibiotics would you give for PROM and why?

IV/oral antibiotics to prevent chorioamnitis and neonatal sepsis

Ceftriaxone and metronidazole common

GBS+ patients may get antibiotics like penicillin G

What physical things would you assess/not assess if someone had a PROM?

• Time of rupture

• Color, consistency, odor

• Avoid vaginal exam

• Maternal history

• FHTs

What are some interventions for preterm labor?

Establish IV access

Monitor VS and contractions

Administer tocolytics if needed

Prepare parent for NICU stay

Polyhydramnios

Excessive amniotic fluid

What percent of pregnancies experience PROM?

2-3%. Higher incidence in black populations.

What is the FERN test?

When amniotic fluid is looked at under a microscope it looks like ferns. Shows presence of PROM.

Explain the different tests to test for PROM (except FERN see above)

Nitrazine test: Assesses pH of vaginal fluid. Amniotic fluid is more basic and blue on the stick. Regular vaginal secretions without PROM are more acidic and yellow.

FERN

Visual inspection

Amniotic protein tests

Ultrasound - can detect low amniotic fluid indicating PROM.