A 32-year-old gravida 2, para 1 at 39 weeks gestation is admitted to the labor and delivery unit in active labor. Her prenatal course has been uncomplicated. On admission, her cervical examination shows 6 cm dilation, 100% effacement, and the fetal presenting part is at -2 station. Thirty minutes later, the patient experiences spontaneous rupture of membranes with a large gush of clear fluid. The continuous fetal heart rate monitor immediately shows a prolonged deceleration to 70/min that does not resolve. A subsequent sterile vaginal examination reveals a pulsating, smooth, rope-like structure in the vaginal canal ahead of the fetal head. Which of the following is the most appropriate initial next step in management?
- Manual elevation of the fetal presenting partCevap
- BManual replacement of the prolapsed structure into the uterus
- CAdministration of a normal saline amnioinfusion
- DPlacement of the patient in the semi-Fowler position
- EExpectant management with continued continuous fetal monitoring
Cevap
Manual elevation of the fetal presenting part
The patient's presentation of sudden, prolonged fetal bradycardia immediately after rupture of membranes, combined with a palpable pulsating mass in the vagina, is diagnostic of an umbilical cord prolapse. Because the fetal presenting part compresses the umbilical cord against the maternal pelvis, blood flow to the fetus is acutely cut off. The most critical initial step in management is to have an examiner insert a hand into the vagina and manually elevate the fetal presenting part off the prolapsed cord. This hand must remain in place to maintain decompression while the patient is urgently transferred to the operating room for an emergent cesarean delivery.
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Anahtar Kavram
Overt umbilical cord prolapse is an obstetric emergency requiring immediate mechanical decompression of the cord by manually elevating the fetal presenting part, followed by emergent cesarean delivery.