Intrapartum Complications: Cord Prolapse, Shoulder Dystocia & Emergencies

intrapartum complications we're going to cover some of the more common complications and complications

that we can do something about intrapartumly in real time and then we're going to go into

even additional complications in class but we're going to hit the high points right now for things that

most require interventions so these are emergency situations all of these require

prompt intervention to ensure best outcome we have other complications that we're going to talk about in class that

are less emergent these are your emerging complications so i like to segregate these into three

categories in my head okay so your first category is the chord prolapse shoulder dystocia and

non-reassuring fetal status these are mostly problems for baby that we don't really see

systemic problems in mom but we're gonna see these for baby and then the second category

maternal postpartum hemorrhage and amniotic fluid embolism are mostly problematic for mom and then

may systemically affect baby the third category uterine rupture and placental abruption

typically affect both mom and baby simultaneously during the antipartum period

regardless of who they affect in to what degree all of these are emergencies that we have to be aware of

assess for know the risks of and how to intervene appropriately and in what amount of time

to give us the best outcome for mom and baby so the first we're going to talk about is cord prolapse you guys are

going to become very familiar with this because you'll do a simulation if you haven't already so this is where the

umbilical cord drops through the cervix before the fetal presenting part which most often

is the head because if we're doing a vaginal delivery head down is preferred

but it could be a different part the pressure by the presenting part onto the

umbilical cord occludes the blood flow and oxygenation to baby this usually results in a severe

variable deceleration seen on your fetal heart rate monitor to diagnose a chord prolapse you do this

by vaginal examination palpating for the cord now sometimes as you can see in the picture

the cord is through the external um cervical os possibly into the vagina possibly

outside the vaginal opening or we have the possibility that we might have an occult cord prolapse which is

the left side of the picture where the cord is slipped down between baby's head and

the cervix are very close to the baby's head in the cervix but not necessarily out to where you

could just see so vaginal examination is always required to diagnose or rule out a chord prolapse

if a chord prolapse is diagnosed we use the examiner's hand to press pressure of the fetal part off

of the umbilical board being very careful to not touch the cord as much as possible

and being careful that the pressure we're placing most likely on baby's head is more on the skull bones and not those

soft um fontenelles or sutures the identified route of delivery in the

event of cord prolapse is an emergency c-section as soon as possible every minute

that this is occurring is decreased blood flow and oxygenation to baby and oxygenation is brain function so the

faster we get this baby delivered the better our outcomes are going to be [Music]

the next complication is shoulder dystocia you're also going to do a simulation on

this complication what happens in a shoulder dystocia is the anterior shoulder of baby

gets stuck on mom's pubic bone this is most often occurring with an lga baby so

bigger babies which means our risk factors for shoulder dystocia

include moms who have diabetes obese moms because they typically have larger babies

um grandma to parity or a mom that has had a shoulder to social before so while the baby is stuck this is after

the head is delivered that the the shoulder gets stuck after the baby's stuck we have a decrease in oxygenation

to baby so the longer the dystocia occurs the worst outcomes for babies are

we have a number of different interventions that we can do to try to release the stuck shoulder

sometimes the very first intervention releases it and it comes out sometimes we make it all the way through the line

it's not a one-size-fits-all approach so mcroberts is super flexion of the legs

essentially putting mom's knees as close to her ears as we can get them this opens up the pelvic outlet as much

as it will possibly go superpubic pressure is the usually the nurse

putting pressure using the heel of their hand right over top of mom's pubic bone ideally pushing on that shoulder that is

stuck to get it to pop out underneath this pubic symphysis the provider can do things called

internal rotation where they try to turn baby to get that shoulder unstuck or

sometimes they can deliver the posterior shoulder first giving more room to deliver that

anterior shoulder it is a possibility that we purposely um the provider not the nurse

would purposely break baby's clavicle take a baby out that is not obviously our first choice of intervention

then there are some other interventions we're going to discuss in class timing is very important during a

shoulder dystocia um best practice tells us that from the time that the shoulder dystocia is

diagnosed to the time baby is out needs to be five minutes or less

so if we have a number of different interventions that we want to try to get baby unstuck

we don't want to spend significantly too long of time on any one intervention before we move on to the next

so out loud closed loop timing of the team is very important and we'll talk about

that more in class and during simulation non-reassuring fetal status so this is referring to

the fetal heart rate monitoring so fetal tachycardia is concerning however it's not as concerning or as

bradycardia bradycardia is much more ominous in regards to fetal heart rate severe repetitive variable decelerations

and late decelerations are not good for baby if those occur for a length of time it decreases baby's

oxygen reserve and leads to acidosis intrauterine resuscitation are usually our first interventions

to fixing baby's heart rate our very last resort is an emergency delivery usually by c-section

so after we have talked about our fetal heart rate monitoring lecture um you'll have a better understanding of

those and then also we'll understand intrauterine resuscitation the poison mnemonic

is a good tool for helping you to remember what the steps of interuterine resuscitation are

the p is for position changes o is to put oxygen on mom i is for iv fluid bolus the s is for

spec in check um checking for either a dropped umbilical cord or

if baby has progressed and is about to be delivered very quickly the second o is to turn off the oxytocin

if it's on and the n stands for notifying the healthcare provider in the event that you've tried all your nursing

interventions and baby's heart rate still isn't up [Music]

maternal postpartum hemorrhage should be review we have covered postpartum hemorrhaging

class you've had it on a test you've done it in simulation so remembering that we

usually see excessive bleeding hypertension tachycardia decrease in o2 cramping and pain reported by mom our

first and foremost intervention is fundal massage hoping to get that uterus to contract

and slow our bleeding other interventions include starting a second iv giving a fluid bolus laying

mom flat or in trendelenburg supplemental o2 quantifying that blood loss and then

using our medication management with oxytocin methodogen side attack hemobait and maybe gxa

amniotic fluid embolism is very big scary hairy monster it does not happen

very often it's actually a very rare complication but when it does it has about an

80 mortality rate which makes it very very severe so this is a problem for mom what

happens is there's a small tear in that amniotic membrane essentially and a small amount of amniotic fluid

leaks into the maternal system under the pressure from labor

so think of it kind of like a pulmonary embolism but the embolism is made of amniotic

fluid not a blood clot so it floats from the uterus up through the circulation and into the lungs

mom often has initial complicate or um signs and symptoms like a pulmonary embolism so she's going to have that

shortness of breath onside of respiratory distress kind of that sense of doom

we might see that initial change in spo2 but this is more serious than a pulmonary embolism in the way that it

leads to hemorrhagic shock via dic and eventually intubation cardiogenic shock all these

things kind of happen as sequelae so it requires very very immediate

supportive interventions in the way of cpr innovating the patient managing the dic

symptoms if this occurs while baby is not delivered baby needs to come out asap

if baby has just been delivered then it's just to focus on mom the problem with immunity fluid embolism

is if you look at that second bullet point the risk factors that's a really extensive list of risk

factors and that's because it doesn't happen very often so that it's really hard for us to pinpoint

oh this is a patient who's going to have this problem very very rare so just knowing that

early identification is important and then early interventions to support is important and then we go from there

[Music] uterine rupture looks very frightening in that picture so what

happens is there's a laceration of the uterine wall while baby is still inside this most

often occurs at the site of a c-section scar or prior surgery to the uterus

in which the muscle tissue is weaker because of that surgery and that opening that scar tissue

um this is the number one risk with vbac so vaginal birth after cesarean this is why those are more risky

than a regular vaginal delivery because of the risk for uterine rupture um it can be not as severe as the

picture shows it can be incomplete small amounts it doesn't have to be all the layers of the

uterus sometimes we catch it way before it gets this bad sometimes it's abrupt and severe and

looks just like the picture um but mom typically feels pain and then the sensation kind of the

pain gives way and we see effects of blood loss both in mom

and baby in the way of the fetal heart rate and mom's vitals and signs and symptoms

um so this is a big risk with vbac deliveries placental abruption is the early

separation of the placenta from the uterine wall now i say early because ideally once

baby's out we want that placenta to detach and be delivered but this is the separation while baby is

still in utero whether that's the anaparum period or intrapartum when we're trying to have

a baby placental abruption is one of those complications that has a really wide

range of severity we can have a very small abruption that is more chronic in nature doesn't

you know hugely affect mom and baby we have this bleeding we monitor really closely

but we can maintain the pregnancy for a while longer all the way to catastrophic complete abruption of the

whole placenta which essentially completely stops blood flow to baby

which is an absolute medical emergency so any bleeding in pregnancy is not to be

assumed normal so when we do have bleeding we assess the fetal heart rate mom's vitals we

quantify the blood loss to give us an objective means of how much that is

and then we formulate a plan of care from there so much of the intervention and plan

depends very greatly on the severity of the abruption and we'll go more in depth to that in

class so there is a quick overview of some of the complications that you're going to be responsible for

understanding in the intrapartum period