NURSING CARE PLAN- PROLAPSED UMBILICAL CORD

ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATIO

DIAGNOSIS N
Objective: Independent:

The cord is Risk of injury Prolapsed umbilical cord After the 8 hour Change maternal -To relieve the FHR returns
visible and related to early occurs when the baby’s intervention, the position, usually pressure of the to normal
palpable cord slips into umbilical cord falls into Fetal heart rate in knee-chest presenting part so rate.
presenting the birth canal ahead of will returns to position. that the oxygen
part. the baby’s head or other normal. can get through
Membranes parts of the baby’s body. the baby. Uncomplica
are raptures. The umbilical cord slips in ted birth of
Impaired gas front or alongside the the viable
exchanged fetal presenting part. It -To protect the infant.
(fetal) related occurs 1 of 200 exposed cord.
Changes in Cover cord with
to interruption pregnancies.
FHR warm saline
of blood flow dressing
from placenta -Expedite
and fetus. This can be a big problem termination of
Signs of fetal
for the fetus in a number threat to infant.
distress. Prepare for
of ways:
immediate
-If the umbilical vein is vaginal or
obstructed, but the cesarean birth.
arteries are still patent,
then the fetus will
continue to pump blood
out to the placenta but
get nothing in return. This
will lead fairly rapidly to Collaborative: -To stop her
hypoxia (no fresh oxygen contractions,
Consider giving
coming in), and relieving pressure
Terbutaline 0.25
hypovolemia (shock, from on the cord.
reduction on available mg SQ
blood volume).
-if the cord is totally
compressed, hypoxia will
develop relatively quickly,
and be aggravated by the
bradycardia that
accompanies the
obstruction of umbilical
arteries.