Fetal Distress

A. Assessment 1. Fetal heart rate less than 120 or greater than 160 beats/min 2. Meconium-stained amniotic fluid 3. Fetal hyperactivity 4. Progressive decrease in baseline variability 5. Severe variable decelerations 6. Late decelerations B. Interventions 1. Place the mother in a lateral position as indicated. 2. Administer oxygen at 8 to 10 L/min via face mask. 3. Discontinue oxytocin (Pitocin) if infusing. 4. Monitor maternal and fetal status. 5. Prepare for emergency cesarean section.

Prolapse of the Umbilical Cord

In umbilical cord prolapse, a loop of the umbilical cord slips down in front of the presenting fetal part (Fig. 23.6) Prolapse may occur at any time after the membranes rupture if the presenting fetal part is not fitted firmly into the cervix. It tends to occur most often with: Premature rupture of membranes Fetal presentation other than cephalic Placenta previa Intrauterine tumors preventing the presenting part from engaging A small fetus Cephalopelvic disproportion preventing firm engagement Hydramnios Multiple gestation The incidence is about 0.5% of cephalic births; this rises as high as 15% to 20% with breech or transverse lies (Kish & Collea, 2007).

Assessment In rare instances, the cord may be felt as the presenting part on an initial vaginal examination during labor. It may also be identified in this position on an ultrasound. When this happens, cesarean birth is necessary before rupture of the membranes occurs. Otherwise, membrane rupture would cause the cord to slide down into the vagina from the pressure exerted by the amniotic fluid. More often, however, cord prolapse is first discovered only after the membranes have ruptured, when a variable deceleration FHR pattern suddenly becomes apparent. The cord may be visible at the vulva. To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of the membranes whether this occurs spontaneously or by amniotomy. Therapeutic Management Cord prolapse automatically leads to cord compression, because the fetal presenting part presses against the cord at the pelvic brim. Management is aimed at relieving pressure on the cord, thereby relieving the compression and the resulting fetal anoxia. This may be done by placing a gloved hand in the vagina and manually elevating the fetal head off the cord, or by placing the woman in a kneechest or Trendelenburg position, which causes the fetal head to fall back from the cord. Administering oxygen at 10 L/min by face mask to the woman is also helpful to improve oxygenation to the fetus. A tocolytic agent may be prescribed to reduce uterine activity and pressure on the fetus. Amnioinfusion (see later) is yet another way to relieve pressure on the cord (Hofmeyr, 2009). If the cord has prolapsed to the extent that it is exposed to room air, drying will begin, leading to atrophy of the umbilical vessels. Do not attempt to push any exposed cord back into the vagina. This may add to the compression by causing knotting or kinking. Instead, cover any exposed portion with a sterile saline compress to prevent drying. If the cervix is fully dilated at the time of the prolapse, the physician may choose to birth the infant quickly, possibly with forceps, to prevent fetal anoxia. If dilatation is incomplete, the birth method of choice is upward pressure on the presenting part, applied by a practitioners hand in the womans vagina, to keep pressure off the cord until the baby can be born by cesarean birth. Prolapsed cord is always an emergency situation, because the reduced blood flow to the

fetus can quickly cause fetal harm. Amnioinfusion. Amnioinfusion is the addition of a sterile fluid into the uterus to supplement the amniotic fluid (Chhabra, Dargan, & Nasare, 2007). The technique neither shortens nor prolongs labor; it just prevents additional cord compression. For this, a sterile catheter is introduced through the cervix into the uterus after rupture of the membranes. It is attached to intravenous tubing, and a solution of warmed normal saline or lactated Ringers solution is rapidly infused. Initially, approximately 500 mL is infused, and then the rate is adjusted to infuse the least amount necessary to maintain a monitor pattern without variable decelerations. Throughout the procedure, urge a woman to lie in a lateral recumbent position to prevent supine hypotension syndrome. Help maintain strict aseptic technique during insertion and while caring for the catheter. Continuously monitor FHR and uterine contractions internally during the infusion. Record maternal temperature hourly to detect infection. Be sure the solution is warmed to body temperature before the infusion, to prevent chilling of the woman and fetus. This can be done by placing the bag of fluid on a radiant heat warmer or by using a blood/fluid warmer before administration. Because there will be a continuous flow of the infusing solution out of the womans vagina during the procedure, change her bed frequently. Also assess that there is constant drainage. If vaginal leakage should stop, it usually means that the fetal head is firmly engaged and all fluid being infused is being held in the uterus. This is dangerous because it could lead to hydramnios (presence of excessive amniotic fluid) and possibly uterine rupture. Fetal Blood Sampling. Although obtaining a fetal oxygen saturation level by inserting a fetal oximeter into the uterus to rest next to the fetal cheek or obtaining a positive response to scalp stimulation usually supplies the information as to whether a fetus is becoming acidotic (see Chapter 15), this information can also be obtained by scalp blood or fetal blood sampling (Lawson & Bienstock, 2007). The oxygen saturation, partial pressures of oxygen (PO2) and carbon dioxide (PCO2), pH, bicarbonate excess, and hematocrit of fetal blood may all be determined during labor if a sample of capillary blood is taken from the fetal

scalp as it presents at the dilated cervix. After cervical dilatation of 3 to 4 cm and rupture of the membranes, the fetal head is visualized by the use of an amnioscopea small, cone-shaped instrument with a light source at the far end. The scalp is cleaned with povidone-iodine and sprayed with silicon. A small scalpel is introduced vaginally into the cervix, and the fetal scalp is nicked. The silicon causes blood to form in beads, which are caught by a capillary tube. The incision is then compressed until the bleeding has stopped. After the procedure, the woman must be observed after two or three contractions to be certain that no new fetal scalp bleeding occurs. Although a blood sample obtained in this way may be analyzed for many parameters, usually only the pH results are necessary. If the fetus is hypoxic, the pH will fall (become acidotic). A scalp blood pH greater than 7.25 is considered normal for a fetus during labor. A pH between 7.21 and 7.25 should be remeasured in 30 minutes. A scalp blood pH lower than 7.20 is acidotic and signifies a level of fetal distress. This technique may be used to verify a heart rate pattern on a monitor that is becoming ominous. It can also be used to verify that no acidosis is occurring, even if a monitor rate is showing decreased variability. Fetal blood sampling involves no pain for the woman, but it may involve an uncomfortable sensation of pressure because of the examining hand in the vagina. Infants who have had internal scalp blood samples taken should not be born by vacuum extraction, because this procedure can lead to renewed bleeding at the puncture site..