Presented by:
Balancar, Robert
Jimenez, Jay
Lebumfacil, Lani Pearl
BSN III-BBB
Fetal Distress
Compromise of the fetus during the antepartum
period (before labor) or intrapartum period (birth process).
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
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
Breathing problems Altered blood supply to the fetus
Abnormal position and presentation of the fetus
Multiple births
Shoulder dystocia
Impaired supply of O2 to the fetus
Umbilical cord prolapse
Nuchal cord
Placental abruption
Premature closure of the fetal ductus arteriosus Agitation of fetus due to lack of O2
Tachycardia Meconium Staining
Initiation of hypoxemia Fetus aspirates meconium
Constriction of fetal peripheral vessels
Compromised respiration
Elevated BP
Fetal fatigue Anaerobic glucose metabolism
Bradycardia Elevated lactate concentration
High-energy phosphates decrease in cerebrum
Fetal brain damage or Death
Nursing Diagnoses:
Decreased Cardiac Output (fetal)
Impaired Gas Exchange (fetal)
Ineffective Tissue Perfusion (fetal)
Anxiety (maternal)
Deficient Knowledge (maternal)
FETAL
DISTRESS
MANAGEMENT
•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
- 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 .
•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 (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
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
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
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
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
Fetomaternal Factors Obstetrical Interventions
•Fetal malpresentation •Artificial rupture of membranes
•Prematurity •Vaginal manipulation of the fetus with
•Multiple gestation ruptured membranes
•Multiparity •External cephalic version
•Rupture of membranes •Internal podalic version
•Polyhydramnios •Stabilising induction of labor
•Insertion of uterine pressure transducer
Umbilical cord prolapses
Frank cord presentation – Occult cord presentation –
cord prolapsed through cervix Cord trapped alongside presenting part
Compression
Drop in tem- Rupture of membrane and amniotic sac – occurs when presenting part is ill fitting
•Footling Breech Presentation Bet. Pelvic brim
parature of
•CPD And presenting
prolapsed
cord •Fetal Abnormaliy part
Vasospasms Fetal blood supply obstructed when cord out of the uterus as the fetus
Moves downward into the pelvis Oxygen and blood
Of
Supply diminishes
Umbilical
Or cut-off
vessels
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
Management
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.
•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.
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.
•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.
•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.
• 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.
•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.
