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IX. Cord Prolapse -happens when the umbilical cord precedes the fetus' exit from theuterus.

-often concurrent with the rupture of the amniotic sac. After this happens the fetus moves downward into the pelvis and puts pressure on the cord. As a result, oxygen and blood supplies to the fetus are diminished or cut-off and the baby must be delivered quickly. - There are two types of cord prolapse: - Overt prolapse- refers to protrusion of the cord in advance of the fetal presenting part, often through the cervical os and into or beyond the vagina. - Occult prolapse- occurs when the cord descends alongside, but not past, the presenting part. RISK FACTORS: Fetal malpresentations Premature infants Multiparous women CAUSES: A fetus that remains at a high station A very small fetus Breech presentations. The footling breech is more likely to be complicated because the feet and the legs are small and do not fill well the pelvis. Transverse lie Polyhydramnios Excessive amniotic fluid Premature rupture of the membranes Placenta previa Intrauterine tumors preventing the presenting part from engaging CPD preventing firm engagement Multiple gestation Delivering more than one baby per pregnancy (twins, triplets, etc.) Premature delivery of the baby An umbilical cord that is longer than usual SIGNS: A loop of cord is felt in vagina or may be seen at the vulva. Fetal bradycardia (sustained) with deceleration (variable) during contraction Client reports feeling the cord within the vagina Umbilical Cord palpated on pelvic exam Can also be diagnosed on Ultrasound. Management -It is an emergency situation and an indication for immediate Caesarean Section if baby is alive and vaginal delivery cannot be effected, immediately. The aim of management is to prevent the presenting part from occluding the cord. X. Amniotic Fluid Related Problems a. Amniotic Fluid Embolism -is a rare and life threatening complication during pregnancy or childbirth, often resulting in death. It occurs when amniotic fluid, foetal cells, hair, or other materials enter the blood system of a pregnant woman. Amniotic fluid is the fluid that surrounds the unborn baby (foetus) during pregnancy. -Amniotic fluid can enter the blood circulation via tears in the uterus or cervix during labour and delivery, or through partial separation of the placenta. -The process of Amniotic Fluid Embolism is not fully understood, but it is considered to occur in 2 phases:

Phase 1: When the mentioned substances enter the blood circulation of the pregnant woman, a reaction occurs that leads to spasm of the pulmonary (lung) blood vessels, interrupting normal blood supply through the heart and lungs. This lack of blood supply is called hypoxia. Hypoxia causes myocardial (heart) and pulmonary capillary (lung blood vessel) damage, which results in heart failure, and severe inflammation of the lungs (Acute Respiratory Distress Syndrome). Phase 2: there is massive blood loss from the uterus, and abnormal clotting of the blood (coagulopathy). This is called the haemorrhagic phase. Both phases may lead to cardiac arrest, and often death. Risk factors include: Older maternal age Multiparity (more than one child) Intense contractions during labour Abdominal trauma Caesarean section Tears in the uterus or cervix Early separation of the placenta from the uterus wall Intestinal material from the foetus entering the womans blood stream Foetal distress Foetal death Male baby -The treatment is supportive. If the patient has a cardiac arrest, cardiopulmonary resuscitation (CPR) will be required. If the woman does not respond to resuscitation, an emergency caesarean section will be performed after the mother has died. The foetus will be monitored closely for signs of distress. There is nothing a pregnant woman can do to prevent having an amniotic fluid embolism. b. Hydramnios - is a condition in which there is too much amniotic fluid around the fetus. It occurs in about 3 to 4 percent of all pregnancies. It is also called polyhydramnios. -Too much amniotic fluid can cause the mother's uterus to become overdistended and may lead to preterm labor or premature rupture of membranes (the amniotic sac). Hydramnios is also associated with birth defects in the fetus. When the amniotic sac ruptures, large amounts of fluid leaving the uterus may increase the risk of placental abruption (early detachment of the placenta) or umbilical cord prolapse (when the cord falls down through the cervical opening) where it may be compressed. -Factors that are associated with hydramnios include the following: Maternal factors: diabetes Fetal factors: gastrointestinal abnormalities that block the passage of fluid abnormal swallowing due to problems with the central nervous system or chromosomal abnormalities twin-to-twin transfusion syndrome heart failure congenital infection (acquired in pregnancy) -Treatment for hydramnios may include: close monitoring the amount of amniotic fluid and frequent follow-up visits with the physician medication (to decrease fetal urine production) amnioreduction - amniocentesis (inserting a needle through the uterus and into the amniotic sac) to remove some of the amniotic fluid; this procedure may need to be repeated. delivery (if complications endanger the well-being of the fetus or mother, then an early delivery may be necessary)

c. Oligohydramnios -Oligohydramnios is a condition in which there is too little amniotic fluid around the fetus. It occurs in about 4 percent of all pregnancies. -Amniotic fluid is important in the development of fetal organs, especially the lungs. Too little fluid for long periods may cause abnormal or incomplete development of the lungs called pulmonary hypoplasia. Intrauterine growth restriction (poor fetal growth) is also associated with decreased amounts of amniotic fluid. Oligohydramnios may be a complication at delivery, increasing the risk for compression of the umbilical cord and aspiration of thick meconium (baby's first bowel movement). -Factors that are associated with oligohydramnios include the following: premature rupture of membranes (before labor) intrauterine growth restriction (poor fetal growth) post-term pregnancy birth defects, especially kidney and urinary tract malformations twin-to-twin transfusion syndrome -Treatment for oligohydramnios may include: closely monitoring the amount of amniotic fluid and frequent follow-up visits with the physician amnioinfusion - instilling a special fluid into the amniotic sac to replace lost or low levels of amniotic fluid. Amnioinfusion is still experimental, but it may be offered during pregnancy in an attempt to help prevent pulmonary hypoplasia (underdeveloped lungs), or at delivery to help prevent compression of the umbilical cord. delivery (if oligohydramnios endangers the well-being of the fetus, then an early delivery may be necessary)

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