Welcome to complications in labor.
Today we're going to talk about what might happen
when things don't go as planned while the patient is in labor.
We're going to talk about six major complications,
what the nurse might do
to recognize that the complications are occurring,
and what we can do to minimize the effects
both to the fetus and to the mother.
Are you ready?
Here we go.
So, there are six major complications,
we're going to talk about.
The first one prolapsed cord.
Then we'll talk about shoulder dystocia,
precipitous labor,
uterine rupture, amniotic fluid embolus,
it's a belong word
and meconium-stained amniotic fluid.
The first complication we'll discuss is prolapsed cord.
So by definition,
a prolapsed cord occurs when the umbilical cord
is actually below the presenting part of the fetus.
Take a look at this picture, and imagine what would happen
if the baby's lifeline,
which is what the umbilical cord actually is,
comes out first.
That's not a good thing. Definitely an emergency.
So let's talk about the risk factors for prolapsed cord.
The first risk factor is fetal malpresentation.
As the name suggests,
the fetus is actually in the pelvis in a way that creates space.
and that space is a problem,
because the cord can actually slip through that space,
and come out first.
So remember,
before we talked about a fetus being in a breech position,
and how that could create space, so bottom first.
Or maybe the fetus is slightly tilted in the pelvis,
and that creates space.
The second risk factor is polyhydramnios.
As the name suggests,
poly meaning a lot, and hydramnios meaning fluid.
If there's a lot of fluid, the fetus could actually float up,
and then create space.
So when the water breaks, then the cords sort of get sucked down
like toys in a bathtub.
The last risk factor is artificial rupture of membranes.
Now, of course, the water could break spontaneously.
But thinking about the times
when we might actually break the water.
This is also known as AROM, Artificial Rupture of Membranes,
A-R-O-M.
I didn't make it up. It's just the word.
Anyway, we rupture the membranes,
and if the fetal station is really high,
then there may be space there for the cord to come sliding down.
Those are the risk factors.
Let's talk about a couple of more
thinking about space.
If we have a very small little tiny Clitus the fetus,
then that also might create space.
So the fluid may be at a normal level,
but we have a really small baby.
And then if the water breaks,
we get that space, and the cord comes down.
And finally, if we have multifetal gestation.
So let's say we have more than one fetus inside,
then there's definitely a greater possibility
of a cord slipping down.
When we think about assessing for prolapsed cord,
one of the really obvious ways we know
that the cord has prolapsed is that we see it.
We could pull back those covers and see the umbilical cord
just sitting right outside the vagina.
We can also sometimes make a guess that we have a prolapsed cord
from what we see on the monitor.
Look at this monitor strip.
And what you'll notice are variable D cells.
Variable D cells are caused by cord compression.
And obviously, if the cord is coming out,
and the baby's presenting part is sitting on top of it,
we're going to have cord compression.
So this might be the pattern that the nurse notes
on the fetal monitor that makes them go
"Hmm, I wonder if there's a cord prolapse."
So, let's talk about managing the prolapse cord.
The very first thing we want to do is call for help.
Now this is one of those times when you don't leave the room
and go to the desk and call for help.
You need to use the call bell
because you need to stay with the client at the bedside.
If the call bells not working, you might give a shout
but do not leave the patient.
When you call for help
make sure that someone is notifying the provider
and the entire OR team.
This might include anesthesia,
and whoever is going to be the second assist,
and whoever might circulate
because the only safe way to deliver this fetus at this point
unless it's on the way out at that exact moment
is by cesarean.
And we want to make sure that those wheels
are already turning.
The next thing we want to do is think about,
how we can relieve the pressure of the presenting part
on the umbilical cord?
So the nurse with a gloved hand of course,
would introduce their fingers into the vagina
and actually push up on the presenting part
to alleviate that pressure.
Now here's the most important part of that.
Do not, do not remove your hand
because the minute you take your hand out,
the presenting part will settle down on top of the cord
and then completely cut off oxygen supply to the baby.
And if the baby is still inside, that's not a good thing.
So the hand has to stay pushing up that presenting part
until the fetus is delivered via cesarean.
That means a ride to the operating room
with the patient on the bed,
we just throw a sheet over you and we all go together.
Now thinking about other ways we can alleviate the pressure
on the umbilical cord,
we can actually change the position of the patient.
So we can put the patient in trendelenburg.
So not a little skinny trendelenburg,
a really deep trendelenburg.
Remember, the idea is that
we're going to get the presenting part
off the umbilical cord.
And to do that,
we have to really use our friend gravity to do that.
If you have a situation where
maybe the patient doesn't have an epidural,
then we can put the patient in knee-chest.
So this is what that looks like.
So again, thinking about the fact
that we can use gravity to relieve the pressure.
The next thing we want to think about
are the times when the cord is actually
extruded out of the vagina, so we can see it.
Once the cord is exposed to air, it gets dry,
and it starts to contract.
And again,
that'll make the flow of oxygen even more difficult.
So we can use warm saline, we can put it on a gauze
and actually wrap it around the cord.
And the part of the cord we're talking about
is the part that's outside of the vagina.
We want to try not to touch it as much as possible.
But in this case, keeping it wet is going to keep it open and patent.
We want to make sure the client has oxygen.
Because whatever air is getting through,
we want to make sure
it's at the highest concentration of oxygen possible.
We want to start an IV,
if the patient already doesn't have one,
because we're going to the OR for a cesarean
also increasing the blood flow
is going to help get more oxygen to the fetus.
Sometimes if the uterus is really contracting,
the provider may order a tocolytic.
And a tocolytic would actually slow the contractions or stop them.
So we don't have another factor
that is really cutting off the blood supply.
Now one of the other things that we want to always think about
when we're talking to clients, when we're in an emergency
is that we want to let them know what's going on.
So imagine, if you're in a room, and then 10 people come rushing in,
we start pulling things out of the wall and chords
to run you to the OR
when just a few minutes ago everything was okay.
If we don't talk to our client and family
and let them know
what we're doing and why we're doing it,
it can make a really intense scary situation,
even worse.