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Unit 13

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21 views31 pages

Unit 13

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bishayabaniya1
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Unit 13

Complication During 2nd stage of


labour
Complication During 2nd stage of labour

• Prolonged second stage

• Fetal distress

• Cord presentation and prolapse

• Maternal distress
CORD PROLAPSE
Cord prolapsed
• When umbilical cord shows descent in relation to fetal
presenting part mostly during labour is known as cord
prolapsed.

• It is mostly seen after rupture of membrane, occasionally a


loop of cord is visible at the vulva.

• It is most common in multiparous women

• There are three clinical types of abnormal descent of the


umbilical cord by the side of the presenting part .

• All these are placed under the heading “cord prolapsed


Types of cord prolapse
Occult prolapsed
• The cord is placed by the side of the presenting part
and is not felt by the finger on the internal
examination.
Cord presentation

• The cord is slipped down below the presenting part


and is felt lying in the intact bag of membrane.
Cord prolapsed
• The cord is lying inside the vagina or outside the
vulva following rupture of the membranes.
Incidence
• The incidence of cord prolapse is about 1 in 300
deliveries
• The incidence of overt cord prolapsed depend on
the type of presentation of the fetus:
Cephalic presentation- 0.5 %
Incidence cont…
• For breech presentation depend on the type of
breech:
Frank breech- 0.5 %
Complete breech- 5 %
Footling breech – 15 %
• Transverse lie – 20 %
Pathophysiology
• A fetal cord prolapsed may occur when there is
adequate room between the fetal parts and the
maternal pelvis
• Predisposing factors include rupture before the
presenting part is engaged in the pelvis
Causes
Mal presentaion:
• Commonest transverse (1 in 5)
• Breech with flexed legs (1 in 20)
• Footling presentation.
Mal position
• Occipito posterior position, high head at term with
early rupture of membrane
Cont….
• Multiparity
• Contracted pelvis; not engaged head
• Polyhydramnios
• Multiple pregnancy
• Unstable lie
• Prematurity
• Malpresentation
• Placental factor; minor degree of placenta praevia
• Iatrogenic: low rupture of membrane manual
rotation of head/version.
Consequence of Cord
Prolapsed
• Compression of cord
• Spasm of cord vessels due to exposure of cord to
air and handling outside vulva.
• Operative trauma to sub oxygenated fetus
• Perinatal mortality-20%
• Maternal morbidity and mortality due to c/s ;
anesthesia, blood loss and infection
Sign and Symptoms
• Cord loop may be seen on vulva or palpate on PV
exam
• Changes in FHS particularly bradycardia
• Excessive fetal movement
• Meconium stained liquor
Diagnosis
• Bradycardia or variable in FHR is associated with
cord prolapsed
• Occult prolapsed is difficult to diagnose. This
condition is suspect if the persistence of variable in
FHR
• Cord presentation is also diagnosed by feeling loops
of the cord and feeling the pulsation of cord
through the intact membranes
Diagnosis cont.…
• Cord prolapsed is diagnosed simply by palpating
loops of the cord in the vaginal canal during vaginal
examination
• A loop of the cord visible outside the vulva in cord
prolapsed
Management of Cord
Prolapse
Principle of management
To relieve pressure on the cord

To find out the fetus is alive or dead

If alive , to deliver expeditiously


Management of Cord
Prolapsed
THIS IS VERY EMERGENCY SITUATION
1. Immediately inform to obstetrician and pediatrician
2. If oxytocin infusion is running ; this should be
stopped
3. Give O2  4-6 lit/min by mask or nasal canal
4. Immediately do PV exam
• Rule out degree of Cervical dilation,presenting part,
station, cord for pulsating
• It should be handled as little as possible
Specific Management
Pulsating cord: if the cord is pulsating, the fetus is
alive.
Diagnose stage of labor by an immediate vaginal
examination
If the woman is in the first stage of labor,
Wearing high level disinfected or sterile gloves,
insert a hand into the vagina and push the
presenting part up to decrease pressure on the
cord and dislodge the presenting part from the
pelvis;
Cont…
Place the other hand on the abdomen in the
suprapubic region to keep the presenting part out
of the pelvis;
Once the presenting part is firmly held above the
pelvic brim, remove the other hand from the
vagina. Keep the hand on the abdomen until C/S;
If available, give salbutamol 0.5mg IV slowly over 2
minutes to reduce contractions;
Perform immediate C/S
Management cont…
• Bladder filling :
To raise the presenting part of the compressed
cord till such time that patient is delivered
The bladder is filled 500-750 ml of NS with a foley’s
catheter
The balloon is inflated and catheter is clamped
The bladder is emptied by unclamping the catheter
before opening the peritoneal cavity for CS
Cont….
• If the women is in second stage of labor.
Expedite delivery with episiotomy and vacuum
extraction or forceps;
If breech presentation, perform breech extraction
and apply piper or long forceps to the after-coming
head;
Prepare for the resuscitation of the newborn
• 5. Postural treatment :
Place the mother in exaggerated elevated with
pillow under the hip Sim’s position to minimize
cord compression
Place the woman in knee chest position which
causes the fetus to gravitate towards the
diaphragm relieving the compression on the head
Positions for management
of cord prolapsed
Positions for management of
cord prolapsed
Cord not pulsating
(fetus is dead)
• If the cord is not pulsating, confirm death with an
USG scan .
• Deliver in the manner that is safest for the woman.
• Labour is allowed to proceed to await spontaneous
delivery
Prognosis cont…

• Maternal:
 Operative delivery involves the risk of anesthesia,
blood loss and infection
Prognosis cont.…
• Fetal :
The fetus is at risk of anoxia due to acute placental
insufficiency from the cord prolapsed
The overall perinatal mortality is about 15- 50 %
If the delivery is completed within 10-30 minutes
the fetal mortality can be reduced to 5-10 %
Avoid cord prolapse or
its effects
• Admission if a transverse , oblique or unstable lie,
noncephalic presentation after 37 weeks of
gestation
• Woman should be advised to present urgently if
there are signs of labour or suspicious of
membranes rupture
• Preterm prelabour rupture of membranes should
be offered admission
Cont…
• AROM should be avoided whenever possible if the
presenting part is unengaged and high
• Rupture the membranes with a high presenting
part, this should be performed with the
arrangement in place for immediate C- section
• Rupture should be avoided on vaginal examination
if the cord is felt below the presenting part

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