- Umbilical cord delivers before the baby
- Umbilical cord is lying alongside or below the presenting part (leg, shoulder, head, etc.) and can be seen/felt in hand.
- Umbilical cord is how fetus gets oxygenation.
- Pressure is applied from the fetus on the displaced cord, then oxygenation is compromised.
- It is the babies oxygen supply can not be delivered before the baby
- This is a medical emergency
- Visualize the cord protruding from vagina
- Feel pulsation or something squishy on a cervical exam
- Decel in fetal heart rate
- Mom may feel something soft and squishy between her legs
- Never try to push presenting part or cord back in
- Elevate presenting part with your hand to relieve pressure
- Have mother get into knee-chest position
- Helps open pelvis
- Place in exaggerated Trendelenburg position
- This shifts baby toward the fundus by gravity, decreasing the pressure on the cord
- Give supplemental O2
- Extra goes to fetus
- Monitor FHR for signs of hypoxia (increased variability, bradycardia)
- Prepare for emergent immediate delivery (c-section)
- Baby can never deliver after the umbilical cord or placenta = life line
- Knees to chest
- Wearing oxygen will help get more to the fetus
- Nurse is keeping the presenting part off the cord and we are going to OR
In this lesson I will explain prolapsed umbilical cord and your role in the care of this patient.
Ok so let’s first review what the umbilical cord is doing. The umbilical cord is how fetus gets oxygenation. So now a prolapsed umbilical cord. This means that the umbilical cord starts to be delivered prior to the fetus. This is so bad! So pressure is applied from the fetus on the displaced cord. So what’s the problem? Pressure on the oxygen supply is the problem so oxygen supply is compromised. The babies oxygen supply can not be delivered before the baby. This is a medical emergency!
So the assessment of this is going to be either a visualization of the cord protruding from vagina or you feel a pulsation or something squishy on a cervical exam. So remember the cord is compressed so we will see decelerations in the fetal heart rate. This is a reason why it becomes such an emergency! You can see in this image how that cord is coming through the cervix.
Ok so our management of this patient is going to never ever EVER include pushing the presenting part or cord back in. So don’t answer like that if you are asked. Instead we are going to do a lot of other things very fast and all at once! Remember this is an emergency! So we want to elevate the presenting part with your hand to relieve pressure on the cord. The mother needs to be put in either knee to chest position to open the pelvis or in trendelenburg to shift the fetus and relieve pressure.
While you are doing all of this you are also going to give supplemental oxygen. So if you are told that your patient’s saturation is 100% it doesn’t matter you are going to give her oxygen. The extra oxygen is going to help the fetus. The fetal heart rate will be watched for signs of hypoxia. This will show as increased variability or bradycardia. The patient needs to be taken to the OR and prepared for an emergent immediate delivery by c-section. It is important to remember that the baby can never deliver after the umbilical cord or placenta. That umbilical cord and placenta are the life line. So after hearing all the things you need to do I’m sure you are thinking I have two hands, how will I do that? Well this is all done super fast and at once but you are going to have help. You need to call for help immediately. If you realize the cord is out you relieve pressure and yank the call bell from the wall with the other hand. Yanking that call bell out will get lots of help! We had a patient once that the doctor came to AROM her. The fetal head was not engaged. So the head wasn’t low to block the cord from getting out first. When she ruptured her all the fluid came pouring out and so did the umbilical cord. And we had to do all of these things for the patient. If you ever have a patient and know that the fetal head is not well engaged you need to advocate and just tell the doctor “hey when I checked her the head was not well engaged.” Then hopefully the doctor will double check or think twice. If the physician still chooses to rupture the patient then at least you have spoken up.
Education is going to be super quick and to the point. This is an emergency so it is one of those times that we might have to just explain later. We need to get the patient in position so if it is knees to chest then we tell her to get knees to chest to relieve pressure on the baby. We are putting oxygen on her and just say it is for extra to get to the baby. Clearly if you are between her legs and she is being rushed to the OR then you need to explain what is happening. So educating her that you are staying there to keep the pressure off the cord and that we are going to the OR so we can deliver her baby safely.In these situations everyone’s adrenaline is going crazy and the patient can sense that and she is scared. The first time it happens you will be scared but staying as calm as you can will help. Tell the patient to deep breathe and do it with her! In these situations everyone is all hands on deck and helping.
Perfusion and Safety are our concepts because we are concerned about the safety of the fetus with it’s life line hanging out and we are concerned about adequate perfusion with the cord being compressed.
Let’s review what we have learned! So the umbilical cord has come out first. Big problem! The umbilical cord cannot deliver first. We have to relieve pressure so lift the presenting part. Give extra oxygen. Remember it doesn’t matter if mom is 100% the excess goes to the fetus. Position mom in trendelenburg or knees to chest. This is an emergency so act fast and get to the operating room. So in these deliveries someone has to stay between the patient’s legs to keep lifting the head off the cord until deliver has happened. You can’t get you rpatient to the OR and be like alright my job is done. You will stay like that to continue to relieve pressure off of the cord. This happened to my best friend. She came to the hospital in labor. Third baby and was going to be such an easy delivery. I was working the next day so the plan was I would be there to catch and take care of her baby. Well I got to work and she had delivered by c-section. So the doctor when to check and see how dilated she was around 5am and her bag of water ruptured at the same time and the umbilical cord was in the doctor’s hand. So they rushed her to the back and a nurse switched places with the doctor so she could perform the surgery and the nurse held the head off the cord. Everyone was healthy and all is well but I know she always thinks that it could have gone very differently had she ruptured at home or not in the hospital.
Make sure you check out the resources attached to this lesson and review how you will emergently take care of this patient. Now, go out and be your best selves today. And, as always, happy nursing.