Labor is a complex physiological process involving a series of uterine contractions that facilitate cervical dilation and effacement, enabling fetal descent through the birth canal. While labor typically commences around the estimated due date (EDD), its precise onset remains unpredictable. Nurses play a crucial role in monitoring and managing labor, especially when complications like umbilical cord prolapse arise.
Umbilical cord prolapse is a critical obstetric emergency where the umbilical cord descends into the birth canal ahead of the fetus. This compression of the umbilical cord can severely compromise fetal oxygenation, necessitating immediate recognition and intervention. This article delves into the essential aspects of umbilical cord prolapse, providing a comprehensive nursing care plan and diagnostic insights to guide healthcare professionals in ensuring optimal maternal and fetal outcomes.
Stages of Labor: An Overview
To understand the context of potential complications like cord prolapse, it’s important to briefly review the stages of labor:
Stage 1: Early and Active Labor: This is the longest stage, characterized by the onset of regular uterine contractions. Early labor involves initial cervical dilation, progressing to active labor with stronger, more frequent contractions and cervical dilation from 4 to 6 centimeters. Patients are typically advised to go to the hospital when contractions are about five minutes apart.
Stage 2: Delivery of the Baby: This stage begins when the cervix is fully dilated to 10 centimeters and culminates with the birth of the baby. Contractions are intense and frequent, and the mother actively pushes to aid fetal descent and delivery.
Stage 3: Delivery of the Placenta: Following the baby’s birth, the uterus continues to contract to expel the placenta. This final stage completes the birthing process.
Delivery can occur vaginally or via Cesarean section (C-section), depending on maternal and fetal factors. Vaginal delivery is generally preferred due to lower complication risks and faster maternal recovery. C-sections are performed when vaginal delivery is contraindicated, or in emergency situations such as fetal distress, placental abruption, umbilical cord prolapse, or hemorrhage.
The Crucial Role of the Labor and Delivery Nurse
Labor and delivery nurses are pivotal in providing holistic care to women and their newborns throughout the perinatal period. They are the primary point of contact between the patient and the medical team, offering continuous support, education, comfort measures, and updates on labor progress. Nurses are also responsible for recognizing and responding to obstetric emergencies, including umbilical cord prolapse. In C-section deliveries, nurses may assist in the surgical procedure.
Nursing Assessment in Labor and Delivery
The nursing process begins with a comprehensive assessment, gathering subjective and objective data to inform individualized care.
Review of Health History
1. Prenatal Care Review: A thorough review of prenatal records is essential to identify potential risk factors and confirm the estimated due date.
2. Comprehensive History Taking: Nurses should inquire about fetal movement, contraction frequency and timing, amniotic membrane status (ruptured or intact), and any vaginal bleeding. The mother’s medical, surgical, and obstetric history, along with recent laboratory and imaging results, should also be reviewed.
3. Differentiation of True Labor: It’s crucial to distinguish true labor contractions from Braxton-Hicks contractions, which are irregular, less intense, and often subside with activity changes. True labor contractions are regular, progressively stronger, and lead to cervical change.
Physical Assessment
1. Identifying Signs of Labor: Common signs of labor include:
- Regular, progressive contractions
- Rupture of amniotic membranes (“water breaking”)
- Bloody show (blood-tinged mucus)
- Abdominal and lower back pain
2. Leopold’s Maneuvers: These abdominal palpation techniques determine fetal position:
- First maneuver: Identifies the fetal part in the uterine fundus.
- Second maneuver: Determines the location of the fetal back.
- Third maneuver: Confirms fetal presentation and estimates fetal weight and amniotic fluid volume.
- Fourth maneuver: Assesses fetal engagement in the maternal pelvis.
Abnormal fetal presentations, such as breech, brow, face, or shoulder, can increase the risk of complications, including cord prolapse in certain scenarios (e.g., breech presentation).
3. Vital Signs Monitoring: Elevated blood pressure can indicate preeclampsia, a serious pregnancy complication.
4. Pelvic Examination: This assesses cervical dilation, effacement, and fetal station. A sterile speculum exam confirms amniotic fluid presence if membrane rupture is suspected.
5. Contraction Pattern Monitoring: Contractions progress in strength, frequency, and duration as labor advances.
6. Fetal Station Determination: Fetal station describes the presenting part’s descent in relation to the ischial spines. A negative station indicates the fetus is above the spines, zero station means engaged, and positive stations indicate descent past the spines.
7. Pain Assessment: Using a numeric pain scale helps quantify the mother’s pain level and guide pain management interventions.
Diagnostic Procedures
1. Pelvic Evaluation: Clinical pelvimetry and, in some cases, radiographic methods (CT or MRI) may be used to assess pelvic dimensions and predict potential delivery complications.
2. Routine Lab Tests: Standard labor and delivery labs include:
- Complete blood count (CBC)
- Blood type and screen
- Urinalysis
3. Uterine Contraction Monitoring: External tocometry monitors contraction frequency and duration.
4. Fetal Heart Rate Monitoring: Doppler, external belt, or internal electrode monitoring assesses fetal heart rate (FHR) and patterns, crucial for detecting fetal distress, which can be associated with cord prolapse.
5. Bedside Ultrasound: Ultrasound can confirm fetal presentation and position and identify potential complications requiring C-section.
Nursing Interventions During Labor and Delivery
Nursing interventions are crucial for supporting the laboring woman and ensuring fetal well-being.
General Management During Labor
1. Explain Cervical Exams: Explain the purpose of cervical exams in monitoring labor progress. Limit exams to minimize infection risk, especially after membrane rupture.
2. Encourage Ambulation and Position Changes: Mobility and position changes can aid fetal descent, promote comfort, and potentially improve labor progress.
3. IV Line Insertion: An IV line provides access for medication and fluid administration.
4. Oral Intake: Generally, oral intake is allowed during labor, unless contraindicated. IV fluids may be needed for prolonged labor or restricted oral intake.
5. Pain Management: Offer pharmacological (e.g., epidural, opioids, nitrous oxide) and non-pharmacological pain relief options (e.g., massage, breathing techniques, position changes).
6. Comfort Measures: Create a calming environment (dim lighting, quiet), encourage relaxation techniques, massage, heat/cold application, and support position changes.
7. Amniotomy (Artificial Rupture of Membranes): Prepare for and assist with amniotomy if indicated to augment labor, but recognize it’s not always necessary.
8. Oxytocin Administration: Administer oxytocin as prescribed to augment or induce labor if contractions are inadequate.
9. Prevention of Complications: Be vigilant for potential labor complications and implement preventive measures.
Umbilical Cord Prolapse: Recognition and Immediate Interventions
Umbilical cord prolapse is a critical obstetric emergency requiring swift nursing action. It occurs when the umbilical cord descends below the fetal presenting part and becomes trapped between the fetus and the maternal pelvis. This compression compromises fetal blood flow and oxygenation.
Risk Factors for Cord Prolapse:
- Malpresentation: Breech presentation, transverse lie
- Prematurity: Smaller fetus less likely to fill the pelvis
- Polyhydramnios: Excess amniotic fluid allows more space for cord movement
- Multiple gestation: Increased risk with each fetus
- Artificial rupture of membranes (AROM), especially if the presenting part is not engaged.
Signs and Symptoms of Cord Prolapse:
- Sudden fetal bradycardia or variable decelerations on the fetal monitor: This is often the first and most critical sign.
- Palpation of the umbilical cord during vaginal examination: Feeling a pulsating cord in the vagina confirms prolapse.
- Visible cord protruding from the vagina: In some cases, the cord may be visible externally.
Nursing Diagnosis for Cord Prolapse:
- Risk for Fetal Injury related to umbilical cord prolapse
Nursing Care Plan for Cord Prolapse: Immediate Interventions
Goals:
- Relieve pressure on the umbilical cord.
- Improve fetal oxygenation.
- Prepare for immediate delivery.
Interventions:
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Immediate Recognition and Call for Help: Upon suspecting or confirming cord prolapse, immediately call for physician assistance and activate emergency protocols. Time is critical.
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Manual Elevation of the Presenting Part: The priority is to relieve pressure on the cord. During vaginal examination, if the cord is palpated, keep your examining fingers in the vagina and manually elevate the fetal presenting part off the cord. Do not remove your hand until instructed to do so, usually just prior to Cesarean delivery. This is crucial to maintain fetal blood flow.
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Position the Mother: Reposition the mother immediately to alleviate pressure on the cord. Effective positions include:
- Knee-chest position: Have the mother kneel with her chest and shoulders resting on the bed or examination table. Gravity helps move the fetus away from the pelvic inlet.
- Trendelenburg position: Place the mother in a steep Trendelenburg position (head down, feet elevated). This also uses gravity to displace the fetus cephalad.
- Lateral Sims position: If knee-chest or Trendelenburg are not rapidly achievable, place the mother in a deep left or right lateral Sims position with the hips elevated on pillows.
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Oxygen Administration: Administer high-flow oxygen (8-10 L/min via face mask) to the mother to maximize fetal oxygenation.
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Fetal Heart Rate Monitoring: Continuously monitor fetal heart rate and patterns to assess fetal status. Note any improvements or deteriorations.
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Tocolytic Administration (if ordered): In some cases, a tocolytic medication (uterine relaxant) may be ordered to reduce uterine contractions and further relieve pressure on the cord while preparing for delivery. This is a physician-directed intervention.
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Prepare for Immediate Delivery: Cord prolapse necessitates prompt delivery, typically via Cesarean section, to prevent fetal hypoxia and death. Prepare the mother for emergency C-section. This includes:
- NPO status (nothing by mouth)
- IV fluid bolus
- Pre-operative preparations (abdominal shave prep if time allows, insertion of Foley catheter)
- Informing and reassuring the mother and her support person about the situation and plan.
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Communication and Support: Provide clear, calm explanations to the mother and her support person. Reassure them that immediate action is being taken to ensure the safety of both mother and baby. Maintain a calm and efficient demeanor to minimize anxiety.
Contraindicated Actions in Cord Prolapse:
- Attempting to replace the cord into the uterus: This is not effective and can cause further complications.
- Leaving the mother unattended: Continuous nursing presence is vital.
- Delaying action to gather supplies or equipment: Immediate interventions are paramount. Delegate tasks to other staff members.
Expected Outcomes:
- Umbilical cord compression is relieved.
- Fetal heart rate improves and stabilizes.
- Prompt delivery is achieved.
- Fetal hypoxia is minimized or prevented.
- Neonatal resuscitation is readily available at delivery.
Evaluation:
- Continuously assess fetal heart rate response to interventions.
- Monitor maternal vital signs and condition.
- Evaluate neonatal outcome at delivery and postpartum.
- Debrief the event with the team to identify lessons learned and improve future responses.
Postpartum Monitoring
1. Pain Management: Postpartum pain management, especially after C-section, includes NSAIDs and narcotics. For vaginal delivery, comfort measures include sitz baths, ice packs, and analgesics.
2. Vaginal Discharge (Lochia) Monitoring: Assess lochia rubra, serosa, and alba progression for normal postpartum changes and signs of hemorrhage or infection.
3. Bowel Function: Prevent constipation with stool softeners, high-fiber diet, and hydration.
4. Perineal Hygiene Education: Teach proper perineal care to prevent infection.
5. Emotional Support: Recognize postpartum mood changes and screen for postpartum depression.
6. Breastfeeding Support: Promote breastfeeding and provide lactation support.
7. Postpartum Checkup Reminders: Emphasize the importance of postpartum follow-up appointments.
Nursing Care Plans in Labor and Delivery (General Examples)
Beyond specific emergencies like cord prolapse, nurses develop care plans for common labor and delivery nursing diagnoses. Examples include:
Acute Pain
Nursing Diagnosis: Acute Pain related to muscle contractions and tissue trauma.
As evidenced by: Restlessness, moaning, verbalization of pain, facial grimacing, diaphoresis, tachycardia.
Expected Outcomes: Patient will report decreased pain, demonstrate relaxation techniques, and appear comfortable.
Interventions:
- Pain assessment using a pain scale.
- Rapport building and addressing patient concerns.
- Breathing technique instruction.
- Pain relief option discussion.
- Positioning assistance.
- Comfort measures (massage, pillows, ice).
- Analgesic administration as ordered.
Anxiety
Nursing Diagnosis: Anxiety related to perceived threat to baby, fear of unknown, pain, or surgical intervention.
As evidenced by: Increased tension, restlessness, expressed concerns, altered vital signs.
Expected Outcomes: Patient will verbalize reduced anxiety, express feelings, and utilize support systems.
Interventions:
- Psychological and emotional state assessment.
- Identify specific anxieties.
- Acknowledge feelings and support system.
- Calm demeanor and clear explanations.
- Relaxation technique encouragement.
- Calm environment provision.
Risk for Decreased Cardiac Output
Nursing Diagnosis: Risk for Decreased Cardiac Output related to labor complications, bleeding, fluid imbalances.
As evidenced by: (Risk diagnosis – no current signs/symptoms; interventions are preventative).
Expected Outcomes: Patient will maintain stable vital signs, and fetal heart rate will remain within normal limits.
Interventions:
- Regular vital sign assessment.
- Fetal heart rate monitoring.
- Left lateral positioning.
- Monitor for bleeding.
- Oxygen administration as needed.
- Post-anesthesia vital sign monitoring.
Risk for Imbalanced Fluid Volume
Nursing Diagnosis: Risk for Imbalanced Fluid Volume related to blood loss, dehydration, nausea/vomiting.
As evidenced by: (Risk diagnosis – no current signs/symptoms; interventions are preventative).
Expected Outcomes: Patient will maintain normal urine output and stable vital signs.
Interventions:
- Assess risk factors for fluid imbalance.
- Monitor laboratory values (CBC).
- Vital sign monitoring.
- Monitor BP and pulse during oxytocin infusion.
- Encourage oral fluid intake.
- Administer IV fluids as indicated.
- Intake and output monitoring.
Risk for Infection
Nursing Diagnosis: Risk for Infection related to ruptured membranes, vaginal exams, umbilical cord prolapse (increased risk if cord is exposed).
As evidenced by: (Risk diagnosis – no current signs/symptoms; interventions are preventative).
Expected Outcomes: Patient will verbalize infection signs/symptoms, maintain a clean environment, and remain free from infection.
Interventions:
- Assess amniotic fluid for color, odor.
- Monitor fetal heart rate for tachycardia.
- Monitor maternal vital signs and WBC count.
- Limit vaginal exams.
- Aseptic technique for procedures.
- Perineal care and handwashing education.
- Antibiotic administration as prescribed.
- Oxytocin administration as prescribed (to expedite delivery and reduce prolonged membrane rupture).
Conclusion
Umbilical cord prolapse is a life-threatening obstetric emergency demanding immediate recognition and skilled nursing intervention. A systematic nursing approach, encompassing rapid assessment, prompt intervention to relieve cord compression, and preparation for immediate delivery, is crucial for optimizing fetal outcomes. Labor and delivery nurses are at the forefront of recognizing and managing this complication, highlighting their vital role in ensuring safe childbirth. Continuous education, simulation training, and adherence to established protocols are essential to maintain competency in managing cord prolapse and other obstetric emergencies, ultimately contributing to improved maternal and neonatal health.
Alt text: A pregnant woman in active labor, demonstrating breathing techniques to manage contractions, highlighting the importance of pain management in the labor process.
Alt text: Illustration depicting Leopold’s Maneuvers, a systematic method of abdominal palpation used by nurses to determine fetal position and presentation during prenatal assessments and labor.
Alt text: Image of fetal heart monitoring equipment being used during labor, emphasizing the continuous assessment of fetal well-being and prompt detection of fetal distress.
Alt text: A laboring woman utilizing a birthing ball for comfort and pain relief, demonstrating non-pharmacological pain management techniques during labor.
Alt text: A postpartum nurse educating a new mother on newborn care and breastfeeding, illustrating the comprehensive care provided by nurses after delivery.
