Maternity - L&D, part 9: Labor Dystocia, Prolapsed Umbilical Cord, Cesarean Section

Hi, I'm Meris with Level Up RN. And in this video, I'm going to be talking to you about labor dystocia, prolapsed umbilical cords, and C-section births. I'm going to be following along using our maternity flashcards which are available on our website, leveluprn.com, if you want to grab a set of your own. And if you already have a set, I would invite you to follow along with me. So let's go ahead and get started.

I'm going to start here with labor dystocia. So what is dystocia? It just means a prolonged or difficult birth. So this can be for multiple reasons. Fetal macrosomia, so a big baby is going to be one of the reasons for dystocia, right? This is going to be because that's a big baby to get through the pelvis, so that's one possible reason. Maternal fatigue. Think about being in labor for hours and hours, possibly even days, Mom is going to tire out. It's just going to happen. Uterine abnormalities, so maybe the structure of the uterus is different or there's a weakness to it. Cephalopelvic disproportion, which is a fancy way of saying that head is way too big to get through that pelvis. And then fetal malpresentation, if the baby isn't in a good position for labor, that can prolong things or make it more difficult. And then also anesthetic or analgesic use can contribute to dystocia because, for instance, if we have an epidural that is too strong, we're not going to be able to push effectively as an example.

So signs and symptoms here, we're not progressing, right? The dilation is not moving forward, right? We're not fully dilated, maybe we're not fully effaced, and maybe the fetus just isn't descending. That fetal station isn't changing. All of those would be signs and symptoms. Now we would want to encourage our patient to ambulate or change positions if it is allowed. So if they have a very heavy epidural, they're not going to be walking, but we can help them to change positions that may help to move the baby to help rotate things or get things moving. But if we want to get the baby from the posterior to the anterior position, referring to where the back of the head is, then we would want to position the patient on their hands and knees to help get into that sort of position.

Now there's something called shoulder dystocia, and shoulder dystocia refers to when the fetal shoulder gets stuck on the maternal pelvis and this is a true emergency. This can cause all kinds of damage to the nerves and the muscles, even the bones. We can cause bone breaks here when the baby is stuck like that. This is a very big deal. So you need to know that when we have a patient with shoulder dystocia, the place that the nurse may be asked to put pressure is on the suprapubic region. So right above that pubic bone, we're going to push down, and that's hopefully going to help to pop that shoulder down off of that pelvic bone. We can also help to perform McRoberts maneuver. So McRoberts maneuver is going to be something that can be done for shoulder dystocia. Now, other things that we can do for dystocia in general would be assisting with an amniotomy. We can administer oxytocin as ordered, and we may have to prepare for an assisted delivery or for surgical birth through a C-section.

Moving on to prolapsed umbilical cord. So if you have seen previous videos where we talk about fetal heart rate monitoring or we talk about amniotomies and all of these different things, and we've mentioned prolapsed umbilical cords, but let's really talk about what it is and what we should be doing for this. So a prolapsed umbilical cord means that the cord itself is protruding through the cervix before the baby. So baby is still fully inside the uterus, but that cord is poking out through the cervix. This can lead to cord compression, and cord compression can lead to fetal hypoxia, fetal distress, compromised fetal circulation. So remember that that cord is not just like pretty decoration for the uterus, right? That's how the baby is getting that rich oxygenated blood to the baby and getting rid of waste and carbon dioxide so that Mom can get that stuff out, right? So if we have prolapse and compression, it's having a big effect on the baby.

Now, how do we know this? Well, first, we could either see it, right? It might be fully out of the vagina or we feel it, perhaps we're doing a cervical check and we feel something poking out that doesn't feel like a part of the baby. That's when we're going, "Oh no," right? And, again, we talked about variable decelerations being caused by cord compression. So if I saw those, I might say, "Oh no, we could have a prolapsed cord." So nursing care, number one is calling for assistance. You need help, but don't leave your patient. So that could be literally calling out, "I need help in here," pushing some kind of emergency button or panic button either in the room or, for instance, at work, I have a panic button on my badge so that I can get help immediately and it tracks where I am also. And then I need to apply sterile gloves - not clean gloves, sterile gloves - and I'm going to insert my fingers into the patient's vagina. And what I'm going to do is I'm basically going to try and get my fingers one on either side of the cord, and I want to try and lift the fetal presenting part off of that cord. So literally fingers going in, hopefully cord is running in between them, and I'm trying to lift the fetal presenting part off of the cord to reduce some of that compression so that we can still be getting good blood flow.

Next, it would be positioning Mom knee-chest position or Trendelenburg position. We're going to try and use gravity to shift the baby off of that prolapsed cord. And then if the cord is exposed like outside of the vagina, then I need to make sure that it is covered so it's not going to dry up or be exposed to germs. So we need to put a warm, sterile saline-soaked towel over the cord to protect it. We're going to administer oxygen to the patient and we're going to prepare for the birth of the infant. So this is typically going to be with a C-section. So in that instance, the nurse who is lifting that presenting part off of the cord is going to ride on the stretcher to the OR and is going to continue to lift that presenting part off of the cord until the doctor or whoever the provider is delivers that baby through C-section and now there's no longer the need to lift anything off of the cord, right? So it's a true medical emergency and it can lead to fetal death if there is not appropriate intervention.

So now let's talk about C-sections. So cesarean sections which we abbreviate as C-sections, so this is going to be delivery of the infant through an incision that's made in the abdomen and the uterine wall. So literally, we are surgically delivering this baby. And there's a lot of different types of C-sections depending on if it's a classic, transverse, and emergency section, all of these things. But no matter what, we're still doing a surgical procedure to deliver the infant. We can either have spinal anaesthesia, and that would typically be someone who is having a planned C-section. They're going to go and get the spinal anaesthesia which is what I got. It's just the shot into the CSF and that's going to provide anesthesia up until about the nipple level. There can be epidural anesthesia, that would typically be someone who maybe was attempting vaginal delivery, had an epidural catheter placed, and now is going to have a C-section. And also general anesthesia. It's uncommon, this is not the thing that you think of when you think of a C-section, but general anaesthesia can be given to the patient in an emergency situation. So we sometimes call these splash-and-dash C-sections, meaning that we have a time limit. We have to get baby out. We don't have time to do a spinal and all of these things, so we're going to put Mom to sleep, splash Betadine on the belly and get going, right? We got to get that baby out of there.

So risk factors for C-section, there are so many of them. There's a few here: labor dystocia, fetal malpresentation, failure to progress, right? We're not getting that good dilation and effacement. Fetal distress. Of course, if the baby's in distress, we're going to get them out. And then previous C-section, I had a C-section with my daughter and then I had a C-section with my son. Some patients do choose to VBAC which is vaginal birth after a C-section. However, that comes with a lot of risks and a lot of like kind of things that have to be met for you to be a candidate for that. So in general, if you have had a C-section before, you are likely to just have a planned C-section again in the future. Complications. Of course, as with any sort of surgical procedure, hemorrhage and infection, right? Those are our big concerns in complications for a surgical delivery.

And as far as nursing care, we got to make sure we have a patent IV, right? We're going to start foley in our patients so that we can empty their bladder for them. We're going to run IV fluids, any sort of preoperative medications like antibiotics would be given, and then we need to provide analgesia for post-op pain. In most cases, Duramorph, a form of morphine, is given with the spinal and this actually provides really good analgesia for about 24 hours after delivery. But once that starts to wear off, it's going to be pretty painful. So we need to give those analgesics to our patients. And then we need to, of course, be assessing the incision site itself for signs of infection, purulent drainage, wound dehiscence, anything like that. Of course, that's what we're going to do for any sort of surgical procedure.

So I hope this review was helpful to you. I'm going to give you a quick quiz now so that you can test your understanding of some key points that I gave you in this video. So get your thinking caps on and let's go through it.

For a patient who's experiencing shoulder dystocia, where should the nurse apply pressure? Where should you apply pressure for shoulder dystocia?

[Suprapubic region]

What positions are indicated for a patient experiencing a prolapsed umbilical cord? I told you two of them. See if you can remember both. But even if you get one, that is awesome.

[Trendelenburg or knee-chest position]

And lastly, how should the nurse care for an exposed prolapsed umbilical cord? So I have an umbilical cord that has prolapsed and it is exposed to the outside. What am I going to do to take care of it?

[Cover the umbilical cord with a warm, sterile, saline-soaked towel]

Let me know how you did. I hope you did great. Thanks so much and happy studying.