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October 4, 2010
BSN IV
Definition:
• “Cord prolapse” is when the umbilical cord exits the birth canal prior to baby. If cord prolapse
occurs, the blood and oxygen flow to the baby can be interrupted or severed, which can cause
tissue, oxygen or brain damage.
Etiology:
• Fetal malpresentation
• Prematurity
• Multiple gestation
• Multiparity
• Rupture of membranes
• Polyhydramnios
Obstetric factors:
• Artificial rupture of membranes
• Internal scalp electrode application
• Intra uterine pressure
• Catheter replacement
• Forceps or vacuum application
• Manual rotation of fetal head
Assessment findings:
• vaginal exams identifies cord prolapse into vagina
Nursing intervention:
• Check fetal heart tones immediately when membranes rupture and again after next contraction
or within 5 minutes; report deceleraton.
• If fetal Bradycardia; perform vaginal examination and check for prolapsed cord.
• If cord prolapsed into vagina, exert upward pressure against presenting part to lift part off cord,
reducing pressure on cord.
• Get help to move mother into a position where gravity assists in getting.
presenting part off cord (knee-chest position or severe trendelenburg’s).
• Administer oxygen and prepare for immediate cesarean birth.
• If cord protrudes outside vagina, cover with sterile saline while carrying out
above tasks. Do not attempt to replace cord.
• Notify physician
Assessment findings:
Nursing intervention:
Emergency Delivery of an Infant
Preterm Labor
General information:
• Labor that occurs before the end of the 37th week of pregnancy
• Cause is frequently unknown, but the ff conditions are associated with premature labor:
–Cervical incompetence
–Preeclampsia/eclampsia
–Maternal injury
–Infection
–Multiple births
–Placental disorders
Prevention:
• Minimize or stop smoking; a major factor in preterm labor and birth.
• Minimize or stop substance abuse/chemical dependency.
• Early and consistent prenatal care.
• Appropriate diet/ weight gain.
• Minimize/prevent exposure to infections.
• Learn to recognize signs and symptoms of preterm labor.
Medical management:
• Unless labor is irreversible, or a condition exists in which the mother or fetus would be
jeopardized by the continuation of the pregnancy, or the membranes have ruptured, the usual
medical intervention is to attempt to arrest the premature labor (tocolysis).
• Medications used in the treatment of premature labor:
a. Magnesium sulfate – stops uterine contractions with fewer side effects than beta-
adrenergic drugs.
- Must monitor patient for magnesium toxicity
- Few serious side effects; initially patient feels hot, flushed, may
c/o headache, nausea, diarrhea, dizziness, nystagmus, and lethargy.
- Most common fetal side effect is hypotonia.
b. Beta-adrenergic drugs-Terbutaline and Ritodrine
–Decreases effect of calcium on muscle activation to slow or stop uterine
contractions
- Side effects: increased heart rate, nervousness, tremors, nausea
andvomiting, decrease in serum K+ level, cardiac arrythmias,
pulmonaryedema.
c. Nifedifine – Calcium channel blocker
–Side effects facial flushing, mild hypotension, reflex tachycardia,
headache, nausea
Nursing Intervention:
General information:
Assessment findings:
Rupture of Uterus
Description:
Risk factors:
• Woman who have previous surgery on the uterus
• Prior classical cesareans, where the incision is near the top of the uterus
• Prior removal of fibroid tumors if the incision extended through the full thickness of the
uterine wall
• Any other surgery that went through the full depth of the muscular portion of the uterus
• Grand multiparity
• Fetal malpresentation
• Labor- inducing medications
• Multiple gestation
• bleeding
Prevention:
• Sudden severe abdominal pain in later pregnancy should be reported to your physician,
especially if you are at increased risk for rupture of the uterus.
• Women with risk factors such as prior classical cesarean, deep fibroid excisions,
and other major uterine surgeries should not attempt labor, and should be scheduled for
cesarean as soon as the fetus is expected to do well out in the wolrd, usually 36 and 39 weeks of
gestation.
Assessment:
• Descriptive characteristic of pain, including location, quality, intensity on a scale of 1-10,
temporal factors and sources of relief
• Fluid and electrolyte status, including weight, intake and output, urine specific gravity, skin
turgor, and mucous membranes
• Physiological variables, such as body image, personality, previous experience with pain,
anxiety, and secondary gain
Intervention:
• Assess patient’s signs and symptoms of pain and administer pain medication as prescribed
• Start or maintain an IV fluid as prescribed. Use a large gauge catheter when starting the IV for
blood and large quantities of fluid replacement
• Perform comfort measures to promote relaxation such as relaxation techniques
• Administer fluids, blood or blood products
• Give brief explanation to the woman and her support person before beginning a procedure
• Answer questions that the family or woman may have
• Maintain a quiet and calm atmosphere to enhance relaxation
• Remain with the woman until anesthesia has been administered; offer support as needed