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The term "fetal distress" is commonly used to describe fetal hypoxia (low oxygen levels in the fetus). Causes: Breathing problems Abnormal position and presentation of the fetus Multiple births Shoulder dystocia Umbilical cord prolapse Nuchal cord Placental abruption Premature closure of the fetal ductus arteriosus Slide 3: Signs and Symptoms: Antepartum period: “kick count” less than 10 Cramps with bleeding Intrapartum period: Tachycardia & Bradycardia – especially during contractions Decreased variability in FHR Meconium in the amniotic fluid Fetal acidosis – fetal scalp pH <7.2 Elevated fetal blood lactate levels – lactic acidosis Diagnosis: Non-stress Test Ultrasound Cardiotocography Fetal blood sampling – scalp prick Slide 4: Breathing problems Abnormal position and presentation of the fetus Multiple births Shoulder dystocia Umbilical cord prolapse Nuchal cord Placental abruption Premature closure of the fetal ductus arteriosus Altered blood supply to the fetus Impaired supply of O2 to the fetus Agitation of fetus due to lack of O2 Meconium Staining Tachycardia Constriction of fetal peripheral vessels Initiation of hypoxemia Fetal fatigue Elevated BP Bradycardia Compromised respiration Anaerobic glucose metabolism Fetus aspirates meconium Elevated lactate concentration High-energy phosphates decrease in cerebrum Fetal brain damage or Death Slide 5: Nursing Diagnoses: Decreased Cardiac Output (fetal) Impaired Gas Exchange (fetal) Ineffective Tissue Perfusion (fetal) Anxiety (maternal) Deficient Knowledge (maternal) Slide 6: FETAL DISTRESS MANAGEMENT Slide 7: When fetal distress is present, immediate action must be taken to restore proper blood supply and oxygenation to the baby. If there are signs of fetal distress, the healthcare provider may choose to deliver the baby immediately (often by cesarean section). Often, however, he or she will take other steps first to try to improve and confirm the baby's condition. - alteration of maternal position - hydration - oxygen administration Slide 8: - checked for meconium - fetal scalp stimulation - amnioinfusion If the mother is receiving oxytocin (a drug that induces labor), the healthcare provider may stop giving it. If conservative measures are unsuccessful, immediate delivery of the baby (often by cesarean section) is required . Slide 9: In certain situations, it may be appropriate to resuscitate the baby in the uterus before performing the cesarean delivery: use of medication The fetus must continue to be monitored closely for signs that the treatment is not working, which would require the immediate commencement of the cesarean delivery. The negligence of a healthcare provider to implement an appropriate treatment plan can result in permanent injury, or even death, to baby and mother. Umbilical cord prolapse : Umbilical cord prolapse Umbilical Cord Prolapse (UCP) : Umbilical Cord Prolapse (UCP) A rare, obstetrical emergency that occurs when the umbilical cord descends alongside or beyond the fetal presenting part. It is life threatening to the fetus since blood flow through the umbilical vessels is usually compromised from compression of the cord between the fetus and the uterus, cervix, or pelvic inlet. Types of Umbilical Cord Prolapse : Types of Umbilical Cord Prolapse Overt Prolapse The most common; Refers to protrusion of the cord in advance of the fetal presenting part, often through the cervical os and into or beyond the vagina. The fetal membranes are invariably ruptured in these cases and the cord is visible or palpable on examination. Occult Prolapse Occurs when the cord descends alongside, but not past, the presenting part. It can occur with intact or ruptured membranes. The diagnosis should be considered in the setting of a sudden, prolonged fetal heart rate deceleration. An occult prolapse often cannot be diagnosed with certainty, but is suggested by clinical features (eg, fetal bradycardia) and findings at cesarean delivery. Signs : Signs Ill-fitting or non-engaged presenting part Prolapsed umbilical cord umbilical cord visualized in vagina or at vulva umbilical cord palpated on pelvic exam Fetal distress on Fetal Heart Tracing May follow rupture of membranes Prognosis High perinatal mortality for delayed delivery >40 min Risk Factors : Risk Factors Premature rupture of the amniotic sac Polyhydramnios Having a large volume of amniotic fluid. The cord may be forced out with the more forceful gush of waters. Long umbilical cord Fetal malpresentation Multiparity Multiple gestation Placenta previa Intrauterine tumors Prevents the presenting part from engaging. A small fetus CPD Prevents firm engagement. Diagnostic Test : Diagnostic Test A prolapsed umbilical cord can be diagnosed in several ways: During delivery, a fetal heart monitor is used to measure the baby’s heart rate. If the umbilical cord has prolapsed, the baby may have bradycardia (a heart rate of less than 120 beats per minute) Electric Fetal Monitoring (EFM), also called a cardiotocograph, allows the fetus heartbeat to be viewed in relationship to the mother’s contractions. EFM is the most commonly used instrument for the diagnosis of fetal distress. A pelvic examination can also be conducted by a physician and may see the prolapsed cord, or palpate (feel) the cord with the fingers. Note: Routine ultrasound examination is NOT sufficiently sensitive or specific for identification of cord presentation antenatally and should not be performed to predict increased probability of cord prolapse, unless in the context of a research setting. Pathophysiology : Pathophysiology Drop in tem- parature of prolapsed cord Slide 17: Nursing Diagnoses: Impaired Gas Exchange (fetal) Risk for Injury (fetal) Fear (maternal) Anxiety (maternal) Deficient Knowledge (maternal) Umbilical Cord Prolapse : Umbilical Cord Prolapse Umbilical Cord Prolapse : Umbilical Cord Prolapse Umbilical Cord Prolapse : Umbilical Cord Prolapse Umbilical Cord Prolapse : Umbilical Cord Prolapse Umbilical Cord Prolapse : Umbilical Cord Prolapse Slide 23: Umbilical Cord Prolapse Management Slide 24: Initial management of cord prolapse in hospital setting: When cord prolapse is diagnosed before full dilatation, assistance should be immediately called and preparations made for immediate delivery To prevent vasospasm, there should be minimal handling of loops of cord lying outside the vagina. To prevent cord compression, it is recommended that the presenting part be elevated either manually or by filling the urinary bladder. Slide 25: Cord compression can be further reduced by the mother adopting the knee–chest position or head-down tilt (preferably in left-lateral position). Tocolysis can be considered while preparing for caesarean section if there are persistent fetal heart rate abnormalities after attempts to prevent compression mechanically and when the delivery is likely to be delayed. Although the measures described above are potentially useful during preparation for delivery, they must not result in unnecessary delay. Slide 26: Optimal mode of delivery with cord prolapse: A caesarean section is the recommended mode of delivery in cases of cord prolapse when vaginal delivery is not imminent, to prevent hypoxia–acidosis. A category 1 caesarean section should be performed with the aim of delivering within 30 minutes or lessi f there is cord prolapse associated with a suspicious or pathological fetal heart rate pattern but without unduly risking maternal safety. Verbal consent is satisfactory. Slide 27: Category 2 caesarean section is appropriate for women in whom the fetal heart rate pattern is normal. Regional anaesthesia may be considered in consultation with an experienced anaesthetist. Vaginal birth, in most cases operative, can be attempted at full dilatation if it is anticipated that delivery would be accomplished quickly and safely. Breech extraction can be performed under some circumstances, such as after internal podalic version for the second twin. Slide 28: A practitioner competent in the resuscitation of the newborn should attend all deliveries with cord prolapse. Management in community setting: Women should be advised, over the telephone if necessary, to assume the knee–chest face-down position while waiting for hospital transfer. During emergency ambulance transfer, the knee–chest is potentially unsafe and the left-lateral position should be used. Slide 29: All women with cord prolapse should be advised to be transferred to the nearest consultant-led unit for delivery, unless an immediate vaginal examination by a competent professional reveals that a spontaneous vaginal delivery is imminent. Preparations for transfer should still be made. The presenting part should be elevated during transfer by either manual or bladder filling methods. Iti s recommended that community midwives carry a Foley catheter for this purpose and equipment for fluid infusion. Slide 30: To prevent vasospasm, there should be minimal handling of loops of cord lying outside the vagina. Expectant management should be discussed for cord prolapse complicating pregnancies with gestational age at the limits of viability. Uterine cord replacement may be attempted. Women should be counselled on both continuation and termination of pregnancy following cordprolapse at the threshold of viability. You do not have the permission to view this presentation. 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