SROM question

[LJR89]

My final yesterday asked (more elequently than I am) what is the next thing to do after SROM in a healthy/low risk pregnancy.

I narrowed down my choices to either:

1)Document

or

2)check fetal heart rate.

I just can't remember what was said in class and I can't find the answer in any of my materials. I know having the whole question would be ideal, but this is all I remember. What do you think?

[chare]

According to various practice tests and my professor, check fetal heart rate first before everything else.

Really? Doesn't anyone think knowing whether the cord prelapsed might be important?

[umbdude, MSN, APRN]

Really? Doesn't anyone think knowing whether the cord prelapsed might be important?

well...having SROM doesn't necessarily put you at risk for a cord prolapse. However ROM could mean you're contracting and putting more stress on the fetus and fetal hypoxia is really bad.

sorry I'm exactly an expert in OB. I just finished my final yesterday that's all.

[chare]

...sorry I'm exactly an expert in OB. I just finished my final yesterday that's all.

And which final is this?

[bagladyrn, RN]

Really? Doesn't anyone think knowing whether the cord prelapsed might be important?

What would be a sign of cord prolapse? What would the fetal heart rate do and why?

[umbdude, MSN, APRN]

And which final is this?

OB. I did that and psych this semester. just had the finals

[chare]

OB. I did that and psych this semester. just had the finals

Gotcha. Just curious what exactly qualified you as "an expert in OB."

[chare]

What would be a sign of cord prolapse? What would the fetal heart rate do and why?

In prolapse, the cord would exit the lady parts when the membranes ruptured and be visible.

Regarding heart rate, as long as the presenting part doesn't compress the cord, and the fetus receives adequate blood flow, heart rat remains stable. If the cord is compressed and blood supply to the fetus is compromised, severe fetal bradyardia can rapidly occur.

This is why, with SROM it is important to observe for prolapse. If present, place the mother in knee-chest position to minimize fetal descent. Also, someone can insert their hand into the birth canal and keep pressue off the cord.

[umbdude, MSN, APRN]

Gotcha. Just curious what exactly qualified you as "an expert in OB."

oh geez that's a screw up. I meant to say "NOT exactly an expert."

[Alikatz08]

In prolapse, the cord would exit the lady parts when the membranes ruptured and be visible.

Regarding heart rate, as long as the presenting part doesn't compress the cord, and the fetus receives adequate blood flow, heart rat remains stable. If the cord is compressed and blood supply to the fetus is compromised, severe fetal bradyardia can rapidly occur.

This is why, with SROM it is important to observe for prolapse. If present, place the mother in knee-chest position to minimize fetal descent. Also, someone can insert their hand into the birth canal and keep pressue off the cord.

1) It's not always visible, there are varying degrees of cord prolapse, all very serious of course. I have seen a cord actually out of the lady parts once and have dealt with several cord prolapses where it was just compressed in front of the head, but not visible (provider felt it during AROM). Luckily, I haven't come across a large amount of them during my career so far, instead other OB emergencies have been more common where I have to call a Code for (ugh).

2) Remember that even during SROM (or AROM) the head can descend quite rapidly at times as well and even without a cord in the way, the fetus can experience a vagal response and there can be a decel. I've seen this various times, however it returns back to baseline fairly quickly (also seen the heart rate remain at baseline plenty of times as you described). Obviously, with a prolapse it's not going to be returning back to baseline as with simple head compression. I still remember my first cord prolapse emergency like it was yesterday. Definitely scary!

3) Depends on the situation. When a patient on my unit SROM's we aren't checking all of them for cord prolapse, especially if the fetal heart rate doesn't indicate distress. If the mother is on a fetal monitor (which usually is the case majority of the time where I work) and there are normal heart tones with moderate variability and no decels and is ruptured, this indicates the fetus is well oxygenated and doing well. No need for unnecessary lady partsl exams at this point unless indicated (hasn't been examined yet, hasn't been checked in a while, urge to push, or various other reasons). When someone ruptures their membranes we look for two things, how the fetus is doing and what is the color and odor of the amniotic fluid. Usually with AROM the provider will just make sure that the presenting part is the head when it comes down and not the cord.

So, observing the fetal heart tones is important because it will tell us how the fetus is doing and during a cord prolapse (especially not readily visible) it is usually quite obvious that it is not doing well. So that will prompt an immediate lady partsl exam to check and if so immediate action.

Hope some of that info helped! :)

[klone, MSN, RN]

Keep your hands out of the lady parts after SROM!

Don't automatically assume cord prolapse. If the baby shows indications of prolapse, then yes, you would want to check.

And how would the baby show signs of prolapse? Yep...,fetal heart tones.

[bagladyrn, RN]

In prolapse, the cord would exit the lady parts when the membranes ruptured and be visible.

Regarding heart rate, as long as the presenting part doesn't compress the cord, and the fetus receives adequate blood flow, heart rat remains stable. If the cord is compressed and blood supply to the fetus is compromised, severe fetal bradyardia can rapidly occur.

This is why, with SROM it is important to observe for prolapse. If present, place the mother in knee-chest position to minimize fetal descent. Also, someone can insert their hand into the birth canal and keep pressue off the cord.

when I posted the question it was to encourage the students to see if they could come up with the answer. I try to lead without spoon feeding.

[lavenderskies, BSN]

Really? Doesn't anyone think knowing whether the cord prelapsed might be important?

Checking FHT will help assess prolapsed cord. Of course at the same time you are assessing time, color, quantity and a visual prolapse of cord. But as long as the question doesn't have a specific option to check for prolapse then your answer should be check the FHT.