Nursing Care Plan: Nursing Diagnosis of Cord Prolapse in Labor and Delivery

Labor and delivery are complex physiological processes designed to bring a new life into the world. While often progressing naturally, complications can arise that require immediate recognition and intervention by healthcare professionals. Among these obstetric emergencies, umbilical cord prolapse stands out as a critical event demanding swift and coordinated nursing actions. This article delves into the essential aspects of labor and delivery, focusing specifically on the nursing care plan and nursing diagnosis of cord prolapse, aiming to provide a comprehensive guide for nurses and healthcare providers.

Understanding Labor and Delivery: Stages and Nursing Role

Labor is defined as a series of uterine contractions that facilitate the dilation and effacement of the cervix, enabling the fetus to descend through the birth canal and be delivered vaginally. Typically, labor commences around the expected date of delivery (EDD), though the precise onset remains unpredictable. Labor is traditionally divided into three distinct stages:

Stage 1: Early and Active Labor: This is the longest stage, initiating with the onset of regular contractions and concluding with complete cervical dilation. Early labor is characterized by contractions that gradually increase in frequency and intensity. Active labor begins when contractions become more forceful, frequent, and regular, typically around five minutes apart. During this phase, the cervix dilates from 4 to 6 centimeters. Women may experience increasing discomfort and pressure as the baby descends.

Stage 2: Delivery of the Baby: This stage commences once the cervix is fully dilated to 10 centimeters and culminates in the birth of the baby. Contractions are at their peak intensity and frequency, and the mother experiences an overwhelming urge to push. Maternal effort, guided pushing, and uterine contractions work synergistically to deliver the infant.

Stage 3: Delivery of the Placenta: Following the delivery of the baby, the uterus continues to contract, leading to the separation and expulsion of the placenta. This final stage is typically shorter than the previous stages.

Image alt text: Nurse performing Leopold’s maneuvers on a pregnant woman to assess fetal position during labor, demonstrating the four steps of palpation to determine fetal lie, presentation, and engagement.

Nurses play a pivotal role throughout labor and delivery. They are the constant presence for the laboring woman and her support system, providing continuous monitoring, emotional support, education, and advocacy. Labor and delivery nurses are responsible for:

• Assessment: Continuously evaluating maternal and fetal status, including vital signs, contraction patterns, fetal heart rate, and labor progress.
• Planning: Developing and implementing individualized nursing care plans based on assessment findings and patient needs.
• Intervention: Providing comfort measures, pain management, and managing obstetric emergencies.
• Evaluation: Monitoring the effectiveness of interventions and adjusting the care plan as needed.

Nursing Assessment in Labor and Delivery

A thorough nursing assessment is the foundation of effective nursing care during labor and delivery. This assessment encompasses physical, psychosocial, emotional, and diagnostic data collection.

Review of Health History

1. Prenatal Care Review: A comprehensive review of the patient’s prenatal record is essential to identify any pre-existing conditions, pregnancy complications, and risk factors that may impact labor and delivery. Confirming the expected date of delivery (EDD) is also crucial.
2. Detailed History Taking: Obtain a detailed history from the patient, including fetal movement patterns, contraction onset, frequency, duration, and intensity, status of amniotic membranes (ruptured or intact), and presence of vaginal bleeding. Review the mother’s medical, surgical, and obstetric history, along with recent laboratory results and imaging data.
3. Distinguishing True Labor: Differentiate true labor contractions from Braxton-Hicks contractions. True labor contractions are regular, progressively intensify, and lead to cervical change. Braxton-Hicks contractions are irregular, often painless, and subside with changes in activity.

Physical Assessment

1. Signs of Labor Assessment: Assess for key signs of labor, including:

   • Progressive, regular contractions that increase in frequency, duration, and intensity.
   • Rupture of amniotic membranes (ROM), characterized by a gush or leakage of clear fluid.
   • Bloody show – the passage of blood-tinged mucus from the vagina, indicating cervical changes.
   • Pain in the abdomen and lower back, often described as cramping or aching.

2. Leopold’s Maneuvers: Perform Leopold’s maneuvers to systematically palpate the maternal abdomen and determine fetal lie, presentation, position, and engagement. These maneuvers include:

   • First Maneuver: Identifying the fetal part in the fundus (head or breech).
   • Second Maneuver: Locating the fetal back to determine fetal position (left or right).
   • Third Maneuver: Confirming fetal presentation and assessing engagement in the pelvis.
   • Fourth Maneuver: Determining the degree of fetal descent into the pelvis.

3. Vital Sign Monitoring: Regularly monitor maternal vital signs, including blood pressure, pulse, and respirations. Elevated blood pressure may indicate preeclampsia, a serious pregnancy complication.

4. Pelvic Examination: Perform a sterile vaginal examination to assess cervical dilation, effacement (cervical thinning), and fetal station (descent of the presenting part in relation to the ischial spines). Confirm amniotic fluid presence in the cervix if membrane rupture is suspected using a sterile speculum examination.

5. Contraction Pattern Monitoring: Assess the frequency, duration, and intensity of uterine contractions. Contractions typically become more frequent, longer, and stronger as labor progresses.

6. Fetal Station Determination: Determine fetal station to assess the level of fetal descent in the birth canal. Station is measured in centimeters from -5 to +5, with 0 station indicating engagement at the ischial spines.

7. Pain Assessment: Utilize a pain scale (e.g., numeric rating scale) to assess the patient’s pain level and character. Pain assessment should be frequent to guide pain management strategies.

Diagnostic Procedures

1. Pelvic Evaluation Assistance: Assist with clinical pelvimetry (physical assessment of pelvic dimensions) or radiographic pelvimetry (CT or MRI) if indicated to assess pelvic adequacy for vaginal delivery.

2. Routine Lab Sample Collection: Obtain samples for routine laboratory tests, including:

   • Complete blood count (CBC) to assess for anemia and infection.
   • Blood typing and screening for blood transfusion readiness.
   • Urinalysis to assess for proteinuria and infection.

3. Uterine Contraction Monitoring: Initiate external tocodynamometry to continuously monitor uterine contraction frequency and duration.

4. Fetal Heart Rate Monitoring: Apply external fetal heart rate monitoring (Doppler or electronic fetal monitor) or internal fetal scalp electrode as indicated to continuously assess fetal heart rate and patterns.

5. Bedside Ultrasound Assistance: Assist with bedside ultrasonography to confirm fetal presentation, position, and assess amniotic fluid volume. Ultrasound can also help identify potential complications.

Cord Prolapse: An Obstetric Emergency

Umbilical cord prolapse is a critical obstetric emergency occurring when the umbilical cord descends into the birth canal ahead of the fetal presenting part. This can lead to compression of the umbilical cord between the fetus and the maternal pelvis, compromising fetal blood flow and oxygen supply, resulting in fetal distress or even fetal demise if not promptly managed.

Image alt text: Pregnant woman with external fetal monitoring belts in place during labor, showing the tocodynamometer to measure contractions and the Doppler transducer to monitor fetal heart rate, essential for assessing fetal well-being.

Risk Factors for Cord Prolapse

Several factors increase the risk of umbilical cord prolapse:

• Malpresentation: Breech presentation, transverse lie, or unstable lie.
• Prematurity: Smaller fetus with more space for cord descent.
• Multiparity: Increased risk with each subsequent pregnancy.
• Polyhydramnios: Excessive amniotic fluid, allowing more space for cord movement.
• Artificial Rupture of Membranes (AROM): Especially if the presenting part is not engaged.
• Low-lying placenta or placenta previa: Increased likelihood of cord presentation.
• Unengaged presenting part: Space for the cord to descend.

Nursing Diagnosis of Cord Prolapse

Nursing Diagnosis: Risk for Fetal Injury related to umbilical cord prolapse as evidenced by potential for cord compression and interrupted fetal oxygen supply.

This diagnosis highlights the critical need for immediate nursing interventions to prevent or minimize fetal injury resulting from cord prolapse.

Nursing Care Plan for Cord Prolapse: Goals and Interventions

Expected Outcomes:

• Fetal heart rate will remain within normal limits (110-160 bpm) after intervention.
• Fetus will be delivered with minimal or no neurological sequelae from hypoxia.
• Mother will receive emotional support and understanding during this emergent situation.

Nursing Interventions:

Immediate Actions (Upon Recognition of Cord Prolapse):

1. Call for Help STAT: Activate the emergency obstetric protocol and summon the physician and other necessary personnel immediately. Cord prolapse requires a rapid, coordinated response.
2. Elevate Presenting Part: The MOST critical initial action is to manually elevate the fetal presenting part off the umbilical cord in the vagina. This relieves pressure on the cord and restores fetal blood flow. Maintain this elevation continuously until delivery.
   • Vaginal Elevation: Insert two gloved fingers into the vagina and push the presenting part upwards and off the cord.
   • Maternal Positioning: Simultaneously position the mother in:
     • Knee-chest position: This position uses gravity to help shift the presenting part away from the cord.
     • Trendelenburg position: Head down position, also utilizes gravity.
     • Exaggerated Sims’ position: Lateral position with the upper leg sharply flexed at the hip and knee.
3. Oxygen Administration: Administer high-flow oxygen (8-10 L/min via face mask) to the mother to maximize fetal oxygenation.
4. Fetal Heart Rate Monitoring: Continuously monitor fetal heart rate and patterns. Note any persistent bradycardia, late decelerations, or other signs of fetal distress.
5. Avoid Cord Manipulation: Do not attempt to push the cord back into the uterus. This can further compromise blood flow and potentially damage the cord.
6. Prepare for Immediate Delivery: Cord prolapse typically necessitates immediate delivery, often via Cesarean section, to minimize fetal hypoxia and injury. Prepare the mother for emergency C-section.
   • IV Access: Ensure patent IV access and administer intravenous fluids as ordered.
   • NPO Status: Maintain NPO status in anticipation of surgery.
   • Preoperative Checklist: Complete preoperative checklist and consents as rapidly as possible.
7. Emotional Support: Provide calm and reassuring emotional support to the mother and her partner. Explain the situation clearly and concisely, emphasizing the need for rapid action to ensure the baby’s well-being. Anxiety will be high, so clear communication is crucial.

Ongoing Management:

1. Continued Fetal Monitoring: Maintain continuous fetal heart rate monitoring throughout the emergency management and transport to the operating room.
2. Maternal Vital Sign Monitoring: Monitor maternal vital signs frequently.
3. Documentation: Thoroughly document all assessments, interventions, and maternal and fetal responses. Accurate and timely documentation is essential in emergency situations.
4. Post-Delivery Care: Provide standard postpartum care to the mother after delivery. In addition, provide emotional support and debriefing regarding the emergent nature of the delivery. Monitor the newborn closely for any signs of hypoxia or birth injury.

Nursing Interventions During Labor (General)

While cord prolapse is an emergency, nurses also provide a wide range of interventions for all laboring women to promote comfort, safety, and progress of labor:

1. Cervical Examination Management: Explain the purpose of cervical exams to monitor labor progress. Perform sterile cervical exams as indicated, typically every 2-3 hours unless complications arise. Minimize frequency to reduce infection risk, especially after membrane rupture.
2. Ambulation and Position Changes: Encourage ambulation and frequent position changes as tolerated. Upright positions and movement can facilitate fetal descent and pain relief.
3. Intravenous Fluid Management: Initiate and maintain IV fluids as ordered for hydration and medication administration.
4. Oral Intake: Unless contraindicated, allow oral intake of clear liquids or light foods in early labor. Follow hospital protocols regarding oral intake in active labor.
5. Pain Management: Implement pain management strategies based on patient preference and labor progress. Options include:
   • Pharmacological: Intravenous opioids, epidural analgesia, inhaled nitrous oxide.
   • Non-pharmacological: Breathing techniques, massage, hydrotherapy, counterpressure, relaxation techniques.
6. Comfort Measures: Provide comfort measures to enhance relaxation and reduce discomfort:
   • Create a calming environment (dim lights, quiet surroundings).
   • Encourage walking, rocking, birth ball use, position changes.
   • Massage, acupressure, counterpressure.
   • Heat or cold application.
7. Amniotomy Preparation: Prepare for artificial rupture of membranes (AROM) if indicated to augment labor. Explain the procedure and potential benefits and risks.
8. Oxytocin Administration: Administer oxytocin intravenously as prescribed to augment or induce labor when indicated for slow progress. Monitor uterine contractions and fetal heart rate closely during oxytocin infusion.
9. Complication Prevention: Vigilantly monitor for and manage potential labor complications, such as:
   • First Stage Arrest: Protracted or arrested labor progress.
   • Second Stage Complications: Fetal asphyxia, shoulder dystocia, fetal injury, maternal lacerations, uterine rupture, hemorrhage, amniotic fluid embolism.
   • Third Stage Complications: Postpartum hemorrhage, retained placenta, cord avulsion.

Postpartum Nursing Care

Postpartum nursing care is crucial for maternal recovery and newborn transition. Key nursing interventions include:

1. Pain Control: Manage postpartum pain with analgesics (NSAIDs, opioids as needed). Address afterpains, perineal pain, and incisional pain (C-section). Offer comfort measures like sitz baths, ice packs, and donut pillows.
2. Vaginal Discharge (Lochia) Monitoring: Assess lochia color, amount, and odor. Monitor for excessive bleeding (soaking a pad in an hour or passing large clots). Educate the patient on normal lochia progression (rubra, serosa, alba).
3. Constipation Prevention: Implement measures to prevent postpartum constipation: stool softeners, high-fiber diet, increased fluid intake, hemorrhoid care.
4. Hygiene Education: Teach proper perineal care (front-to-back cleansing, frequent pad changes) and handwashing to prevent infection.
5. Mood and Emotional Assessment: Monitor for postpartum mood changes, “baby blues,” and postpartum depression. Provide emotional support and resources as needed.
6. Breastfeeding Promotion: Support breastfeeding initiation and success. Provide education on positioning, latch, and addressing common breastfeeding challenges. Refer to lactation consultants as needed.
7. Postpartum Checkup Reminders: Educate the patient about the importance of postpartum checkups for maternal and newborn health monitoring.

Conclusion

Nursing care in labor and delivery is multifaceted, demanding expertise in assessment, intervention, and emergency management. Understanding the nursing diagnosis of cord prolapse and implementing a swift and effective nursing care plan is paramount in mitigating fetal risk in this obstetric emergency. By providing comprehensive and compassionate care throughout labor, delivery, and the postpartum period, nurses play an indispensable role in ensuring positive outcomes for mothers and their newborns.

References

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