Prolapsed Umbilical Cord

Umbilical cord slips below/wedges next to presenting part.

• May lead to fetal hypoxia due to cord compression
• Possible cause
• Rupture of membranes without engaged presenting part
• Noncephalic fetal presentation
• Symptoms
• Prolonged variable deceleration
• Pulsating cord palpated upon vaginal examination
• Visible cord at introitus
• Nursing actions
• Stay with patient and call for assistance
• Apply sterile glove and hold pressure of presenting part off umbilical cord
• Place patient in Trendelenburg position
• Notify physician
• Monitor fetal heart tones
• Place sterile saline gauze over any exposed cord
• Notify obstetrical team; prepare for cesarean birth

Shoulder Dystocia

Difficulty with the fetal shoulder passing under the maternal pubic arch.

• Dystocia simulation drills and protocols recommended
• Clinical findings
• Turtle sign
• Delay in delivery of shoulders after delivery of head
• Nursing interventions
• Assess bladder status; catheterize if necessary
• McRobert’s maneuver
• Suprapubic pressure
• Change in maternal position
• Hands-knees
• Squatting
• Lateral recumbent
• After delivery
• Careful assessment for postpartum hemorrhage
• Careful assessment for newborn injury

Vaginal Bleeding

Placenta Previa

Low-lying position of placenta in the uterus that partially or completely covers the cervical os.

Clinical Findings

• Painless, bright red vaginal bleeding
• Bleeding may be reported after intercourse
• Uterine tone soft upon palpation
• Medical intervention dependent on:
• Amount of bleeding
• Labor status
• Gestational age
• Fetal response
• If labor is active and os is completely covered, C/S indicated
• If bleeding is controlled and labor absent, conservative management
• Conservative management teaching
• Activity limitations
• No sexual intercourse or tampon use
• Monitor and report bleeding
• Patient instructed to report placenta placement when admitted to hospital
• Cesarean preparation class
• Count fetal movements

Abruptio Placentae

Premature separation of the placenta; may be partial or complete.

Clinical Findings

• Abdominal pain (sudden onset, intense and localized)
• Fundus firm, boardlike, with little relaxation
• Vaginal bleeding
• Bleeding may be concealed within the uterine cavity
• Alteration in FHR pattern

Nursing Care With Vaginal Bleeding in Late Pregnancy

• Monitor amount of bleeding
• Check vital signs
• Observe for signs of shock
• Evaluate fetal heart tones
• Palpate uterine tone
• Apply electronic fetal monitor (EFM)
• REPORT category II and III FHR patterns
• REPORT tachysystole
• Do not attempt vaginal examination until placenta placement verified
• Initiate IV fluids
• Report laboratory and ultrasound findings
• Prepare staff for possible cesarean birth
• Attend to patient’s emotional needs