00:01
Welcome to
complications in labor.
00:04
Today we're going to talk about
what might happen
when things don't go as planned
while the patient is in labor.
00:11
We're going to talk about
six major complications,
what the nurse might do
to recognize that the complications
are occurring,
and what we can do
to minimize the effects
both to the fetus
and to the mother.
00:23
Are you ready?
Here we go.
00:27
So, there are
six major complications,
we're going to talk about.
00:31
The first one prolapsed cord.
00:34
Then we'll talk about
shoulder dystocia,
precipitous labor,
uterine rupture,
amniotic fluid embolus,
it's a belong word
and meconium-stained
amniotic fluid.
00:46
The first complication we'll discuss
is prolapsed cord.
00:50
So by definition,
a prolapsed cord occurs
when the umbilical cord
is actually below
the presenting part of the fetus.
00:58
Take a look at this picture,
and imagine what would happen
if the baby's lifeline,
which is what
the umbilical cord actually is,
comes out first.
01:08
That's not a good thing.
Definitely an emergency.
01:11
So let's talk about
the risk factors for prolapsed cord.
01:15
The first risk factor
is fetal malpresentation.
01:18
As the name suggests,
the fetus is actually in the pelvis
in a way that creates space.
01:25
and that space is a problem,
because the cord can actually
slip through that space,
and come out first.
01:31
So remember,
before we talked about a fetus
being in a breech position,
and how that could create space,
so bottom first.
01:38
Or maybe the fetus is
slightly tilted in the pelvis,
and that creates space.
01:44
The second risk factor is
polyhydramnios.
01:47
As the name suggests,
poly meaning a lot,
and hydramnios meaning fluid.
01:52
If there's a lot of fluid,
the fetus could actually float up,
and then create space.
01:58
So when the water breaks, then
the cords sort of get sucked down
like toys in a bathtub.
02:04
The last risk factor is
artificial rupture of membranes.
02:07
Now, of course, the water
could break spontaneously.
02:10
But thinking about the times
when we might actually
break the water.
02:14
This is also known as AROM,
Artificial Rupture of Membranes,
A-R-O-M.
02:19
I didn't make it up.
It's just the word.
02:21
Anyway,
we rupture the membranes,
and if the fetal station
is really high,
then there may be space there
for the cord to come sliding down.
02:31
Those are the risk factors.
02:32
Let's talk about
a couple of more
thinking about space.
02:36
If we have a very small little tiny
Clitus the fetus,
then that also might create space.
02:42
So the fluid may be
at a normal level,
but we have a really small baby.
02:46
And then if the water breaks,
we get that space,
and the cord comes down.
02:51
And finally, if we have
multifetal gestation.
02:54
So let's say we have
more than one fetus inside,
then there's definitely
a greater possibility
of a cord slipping down.
03:03
When we think about
assessing for prolapsed cord,
one of the really
obvious ways we know
that the cord has prolapsed
is that we see it.
03:11
We could pull back those covers
and see the umbilical cord
just sitting right outside
the vagina.
03:16
We can also sometimes make a guess
that we have a prolapsed cord
from what we see on the monitor.
03:22
Look at this monitor strip.
03:24
And what you'll notice
are variable D cells.
03:26
Variable D cells
are caused by cord compression.
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And obviously,
if the cord is coming out,
and the baby's presenting part
is sitting on top of it,
we're going to have
cord compression.
03:37
So this might be the pattern
that the nurse notes
on the fetal monitor
that makes them go
"Hmm, I wonder if there's
a cord prolapse."
So, let's talk about
managing the prolapse cord.
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The very first thing we want to do
is call for help.
03:52
Now this is one of those times
when you don't leave the room
and go to the desk
and call for help.
03:56
You need to use the call bell
because you need to stay
with the client at the bedside.
04:02
If the call bells not working,
you might give a shout
but do not leave the patient.
04:07
When you call for help
make sure that someone
is notifying the provider
and the entire OR team.
04:12
This might include
anesthesia,
and whoever is going to be
the second assist,
and whoever might circulate
because the only safe way
to deliver this fetus at this point
unless it's on the way out
at that exact moment
is by cesarean.
04:25
And we want to make sure
that those wheels
are already turning.
04:29
The next thing we want to do
is think about,
how we can relieve the pressure
of the presenting part
on the umbilical cord?
So the nurse with a
gloved hand of course,
would introduce their fingers
into the vagina
and actually push up
on the presenting part
to alleviate that pressure.
04:46
Now here's the most
important part of that.
04:49
Do not,
do not remove your hand
because the minute
you take your hand out,
the presenting part will settle down
on top of the cord
and then completely cut off
oxygen supply to the baby.
05:01
And if the baby is still
inside, that's not a good thing.
05:05
So the hand has to stay
pushing up that presenting part
until the fetus is delivered
via cesarean.
05:14
That means a ride
to the operating room
with the patient on the bed,
we just throw a sheet over you
and we all go together.
05:23
Now thinking about other ways
we can alleviate the pressure
on the umbilical cord,
we can actually change the
position of the patient.
05:30
So we can put the patient
in trendelenburg.
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So not a little
skinny trendelenburg,
a really deep trendelenburg.
05:36
Remember,
the idea is that
we're going to get
the presenting part
off the umbilical cord.
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And to do that,
we have to really use
our friend gravity to do that.
05:46
If you have a situation where
maybe the patient
doesn't have an epidural,
then we can put the patient
in knee-chest.
05:53
So this is what that looks like.
05:55
So again,
thinking about the fact
that we can use gravity
to relieve the pressure.
06:01
The next thing
we want to think about
are the times
when the cord is actually
extruded out of the vagina,
so we can see it.
06:08
Once the cord is exposed to air,
it gets dry,
and it starts to contract.
06:13
And again,
that'll make the flow of oxygen
even more difficult.
06:17
So we can use warm saline,
we can put it on a gauze
and actually
wrap it around the cord.
06:23
And the part of the cord
we're talking about
is the part that's outside
of the vagina.
06:27
We want to try not to touch it
as much as possible.
06:30
But in this case, keeping it wet
is going to keep it open and patent.
06:35
We want to make sure
the client has oxygen.
06:37
Because whatever air
is getting through,
we want to make sure
it's at the highest concentration
of oxygen possible.
06:44
We want to start an IV,
if the patient already
doesn't have one,
because we're going
to the OR for a cesarean
also increasing the blood flow
is going to help
get more oxygen to the fetus.
06:56
Sometimes if the uterus
is really contracting,
the provider may order
a tocolytic.
07:02
And a tocolytic would actually
slow the contractions or stop them.
07:07
So we don't have another factor
that is really cutting off
the blood supply.
07:12
Now one of the other things
that we want to always think about
when we're talking to clients,
when we're in an emergency
is that we want to let
them know what's going on.
07:21
So imagine, if you're in a room,
and then 10 people come rushing in,
we start pulling things
out of the wall and chords
to run you to the OR
when just a few minutes ago
everything was okay.
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If we don't talk
to our client and family
and let them know
what we're doing
and why we're doing it,
it can make a really
intense scary situation,
even worse.