When the cord comes first:
Pregn ancy in cri sis
Umbilical cord prolapse By Mary Dahl Maher, PhD, MPH, RN, CNM, and Elizabeth Heavey, PhD, RN, CNM
Occult umbilical cord prolapse
Overt umbilical cord prolapse
Visiting her mother at the hospital, VG, age 32, was a gravida 3, para 2 at 38 weeks’ gestation. (See Quick guide to pregnancy-related terminology.) As she was riding in the elevator, she experienced a sudden gush of clear fluid and felt something slippery between her legs. She stopped the elevator at the labor and delivery unit and explained to the receptionist what had just happened. The triage nurse had VG get into a bed and quickly removed her jeans to find a 3-in (7.6 cm) loop of coiled, pulsating umbilical cord with no meconium staining at the vaginal introitus. VG was experiencing an umbilical cord prolapse (UCP). This article describes the nurse’s vital role in the management of this obstetric emergency.
July l Nursing2015 l 53
www.Nursing2015.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Rare but urgent A UCP occurs when the fetal umbilical cord enters the birth canal before or alongside the presenting part of the baby. This rare obstetric emergency requires immediate intervention and a collaborative team response to help the infant survive. UCP is described as overt when the cord is palpated in the vagina or seen on the perineum following rupture of membranes; it’s described as occult when the cord isn’t visible but has descended next to but not past the presenting part. A UCP may be suspected when sudden prolonged fetal bradycardia is accompanied by moderate-tosevere variable decelerations, particularly when this change in the fetal heart rate (FHR) occurs after rupture of membranes (ROM). Although UCP can occur spontaneously, risk factors include iatrogenic causes, such as artificial ROM.1 (See What are the risk factors?) The incidence of UCP, estimated to affect 0.1% to 0.6% of total births, has remained constant over the last century.2 Fortunately, rates of fetal morbidity and mortality associated with this disorder have declined due to
The nurse or provider should place a gloved hand intravaginally to elevate the fetal presenting part off the cord. faster responses and improved surgical techniques. The triage nurse called for help and proceeded to elevate VG’s hips by placing the patient in a Trendelenburg position. The nurse began to perform a vaginal exam. As she applied manual pressure to the vertex, she found the
Quick guide to pregnancy-related terminology • Gravida. The number of pregnancies a woman has had. • Para. The number of live births a woman has had. • Multipara. A woman who’s had multiple live births. • Fetal heart rate (FHR) decelerations. When the FHR drops below the established baseline. • Tocolysis. Slowing or inhibiting labor contractions. • Vertex. Cephalic presentation; this means the fetal head enters the pelvis first. • Meconium. The first greenish stool passed by an infant. Its presence at a delivery may indicate fetal maturity or fetal distress. • Cervical status assessment: – Dilation. Measurement of cervical opening at the base of the uterus (10 cm is considered fully dilated). – Effacement. The process of cervical softening and shortening as the tissue thins out to facilitate passage of the fetal head through the cervix (0% to 100%). – Station. The relationship of the presenting fetal part (usually the head) to the ischial spines (0 station), measured in centimeters from –5 above (negative station) to +5 below (positive station).
cervix to be 4 cm (1.6 in) dilated, 70% effaced, and the vertex at −3 station with clear amniotic fluid. During the exam, a second RN arrived to assist, auscultated the FHR at 124 (normal baseline range, 110 to 160), and notified the attending obstetrician and the OR team to prepare for an emergency cesarean section. The triage nurse explained to a distraught VG the implications of her findings and why she’d need to maintain intravaginal manual pressure to keep the vertex lifted off the umbilical cord.3 In a supportive but directive manner, the triage nurse obtained a focused health history, while the second nurse provided supplemental oxygen, obtained peripheral venous access, started an I.V. infusion of lactated Ringer solution at 150 mL/hr, and drew blood specimens for lab work as prescribed (complete blood cell [CBC] count and type and screen). Assessment findings for VG included temperature 97.8° F (36.6° C), pulse 88, respirations 20, and BP 146/68. VG reported she’d last eaten yogurt and a banana for breakfast 3 hours before. The unit secretary retrieved the patient’s prenatal record and contacted VG’s husband. Nursing management: Emergency response The triage nurse should tell the patient what’s happening, providing clear information with emotional support, and call for assistance while beginning immediate interventions to prevent cord compression, which could result in fetal hypoxia. The patient’s hips should be elevated using a modified Sims, Trendelenburg, or knee-chest position. The nurse or provider should place a gloved hand intravaginally to elevate the fetal presenting part off the cord and be prepared to maintain this intervention until delivery.1 Minimizing direct handling or manipulation of the cord is extremely important because it can lead to vasospasm and fetal hypoxia. If the
54 l Nursing2015 l July
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
umbilical cord is overtly prolapsed and transfer of the patient is needed, the cord can be gently replaced into the vagina and warmed sterile saline gauze can be applied at the introitus. The FHR should be auscultated, and continuous electronic fetal monitoring initiated. Oxygen should be delivered by mask at 8 to 10 L/min to promote fetal oxygenation and improve uteroplacental blood flow.3 As soon as possible, peripheral venous access should be obtained for fluid administration (the fluid will depend on provider preference and timing will depend on the timeframe to delivery); blood specimens obtained for CBC count, type, and Rh factor; and the mother prepared for cesarean delivery.1 The senior obstetric resident obtained informed consent from VG to proceed with a cesarean section. The FHR on an external fetal monitor ranged between 118 bpm and 134 bpm, with an occasional variable to 100 bpm. Eighteen minutes after her arrival on the unit, VG was wheeled into the OR with the triage nurse riding alongside her on the bed, still using her hand to apply pressure to the fetal head to keep it from pressing on the umbilical cord. In cases of UCP when delivery appears imminent, it’s possible to encourage the mother in pushing efforts while preparing for cesarean section as long as the FHR isn’t severely compromised.1 However, in this case scenario, spontaneous ROM occurred before the mother was aware of any contractions and her cervical exam was consistent with that of a multipara in early labor, so the patient didn’t have an urge to push and delivery wasn’t imminent. An urgent surgical delivery was indicated. The decision regarding anesthesia is based on many factors, including patient preference, medical status, and contraindications.4 Depending on the patient’s status and the hospital
What are the risk factors?1 Fetal features • Fetal malpresentation (nonvertex fetal presentation) • Unengaged vertex • Congenital anomalies • Prematurity • Small for gestational age Maternal pregnancy-related factors • Multiple gestation • Multiparity • Polyhydramnios—abnormally increased amniotic fluid • Spontaneous ROM Iatrogenic issues • Amniotomy—artificial ROM, when the provider intentionally ruptures the amniotic sac to release the amniotic fluid, sometimes done to speed up labor • Amnioinfusion—instilling fluid into the amniotic cavity • Manual rotation of the fetal head or other obstetric manipulation • External cephalic version—manually rotating a breech fetus to a vertex presentation • Placement of the cervical ripening balloon—a catheter placed into the cervix and filled with saline, which applies pressure to the cervix and promotes dilation and effacement for nonpharmacologic labor induction • Placement of an intrauterine pressure catheter or fetal scalp electrode.
setting, a cesarean section is usually performed under general anesthesia. However, if the FHR is stable with the mother in a knee-chest position, spinal anesthesia may be preferred because fewer maternal risks are associated with it.5,6 VG said she wanted to attempt spinal anesthesia rather than general anesthesia as long as the baby was stable. External fetal monitoring revealed the FHR to be stable, ranging between 120 bpm and 140 bpm with an occasional variable to 90 bpm. After VG was wheeled to the OR, the attending obstetrician directed the triage nurse to remove her hand after the patient was repositioned into a kneechest position. Continuous external fetal monitoring was maintained while the anesthesiologist administered spinal anesthesia. VG was transferred to the OR table with the FHR at 116 bpm to 128 bpm. A low transverse incision was made 35 minutes after the patient presented
to the receptionist. A female infant was delivered; her Apgar scores were 8 at 1 minute and 9 at 5 minutes. (See Understanding Apgar scores.) At 6 lb 4 oz (2.8 kg), she weighed almost 2 lb (0.9 kg) less than her two older brothers did at birth. VG’s husband arrived at the OR shortly after the birth and supported VG for the remainder of the surgical repair. The immediate postpartum period was uncomplicated, and the baby was put skin-to-skin in the recovery room. She successfully latched on the breast for the initial feeding. Documentation pointers In an emergency situation, be sure to identify a team member who’s responsible for maintaining a detailed record of maternal-fetal status, interventions, and response. Such items should include the following: • time of UCP • condition of the cord (color, pulsation, overall character) July l Nursing2015 l 55
www.Nursing2015.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
• notification of the obstetrician • the timing, sequence, and outcomes of nursing interventions, such as maternal positioning and administration of I.V. fluids and oxygen • fetal response to manual elevation of the presenting part to alleviate cord compression • obstetrician arrival time • type of anesthesia • the maternal and newborn status postinterventions.7 When rapid response is delayed With the increasing availability of rapid response with access to surgical delivery, optimal newborn outcomes in emergency situations, such as outlined in this case, have increased. Guidelines recommend that all hospitals be capable of beginning a cesarean section within 30 minutes of the decision to operate.8 The time to actual delivery and mode of delivery chosen should be based on the timing that best incorporates maternal and fetal risks and benefits.3
In cases where immediate surgical delivery isn’t possible, other interventions have been suggested in the literature. Bladder filling involves inserting a urinary catheter into the bladder, filling the bladder with 500 to 700 mL of 0.9% sodium chloride solution, and clamping; the idea is that the full bladder will push the presenting part upward and relieve cord compression. Tocolysis may be helpful if fetal distress is present. Sterile gauze saturated with sterile saline may be used to prevent the cord from drying out.1 Implications for team training In caring for a patient like VG, one of the RN’s primary responsibilities is to ensure a safe environment in which the patient can labor and give birth. This requires effective leadership, a shared family-centered philosophy, interprofessional collaboration, and excellence in key clinical practices.6,9 The efficiency and effectiveness of an emergency response can be greatly
Understanding Apgar scores The Apgar score is used for a rapid standardized assessment of an infant’s initial status after delivery and early in the neonatal transition period. The score is calculated at 1 minute after birth and repeated at 5 minutes after birth. Five measures are assessed and scored 0, 1, or 2 points each and then totaled. A 5-minute Apgar score of 7 or greater is considered normal. Most healthy infants won’t have an Apgar score of 10 because acrocyanosis, or blue discoloration of the hands and feet, is a normal observation in a healthy infant. If the 5-minute Apgar score is less than 7, it’s recommended that the infant continue to be assessed and the score recalculated every 5 minutes for up to 20 minutes. The Apgar score isn’t a predictor of future health status; rather, it’s an assessment of initial infant status. Points
0
1
2
Respiratory effort
None
Weak cry, Strong cry; rate and effort of hypoventilation breathing are normal
Heart rate
None
100 bpm
Muscle tone
Limp
Some flexion
Active motion
Reflex irritability
None
Grimace
Cry or active withdrawal
Color
Pallor or cyanosis Acrocyanosis
Normal
Source: Adapted from ACOG (2006, reaffirmed 2010). Committee Opinion #333: The Apgar score. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co333.pdf?dmc= 1&ts=20141206T0645151146.
enhanced by interprofessional education. Healthcare simulation and experiential training can help prepare staff to respond effectively to rare but lifethreatening situations.10 Interprofessional teamwork is a critical aspect of providing high-quality care during obstetric emergencies.10 ■ REFERENCES 1. Holbrook BD, Phelan ST. Umbilical cord prolapse: a plan for an OB emergency. Contemp OB/GYN. 2013;58(9):30-36. 2. Lin MG. Umbilical cord prolapse. Obstet Gynecol Surv. 2006;61(4):269-277. 3. American College of Obstetricians and Gynecologists. Practice bulletin no. 116: management of intrapartum fetal heart rate tracings. Obstet Gyencol. 2010;116(5):1232-1240. Reaffirmed 2013. 4. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. ACOG committee opinion. No. 339: Analgesia and cesarean delivery rates. Obstet Gynecol. 2006;107(6):1487-1488. Reaffirmed 2013. 5. Ginosar Y, Weiniger C, Elchalal U, Davidson E. Emergency Cesarean delivery for umbilical cord prolapse: the head-down, knee-chest prone position for spinal anesthesia. Can J Anaesth. 2008;55(9): 612-615. 6. Chebsey CS, Fox R, Draycott TJ, Sissakos D, Winter C. Umbilical Cord Prolapse. 2nd ed. GreenTop Guideline No. 50. London, UK: Royal College of Obstetricians and Gynaecologists; 2014. 7. Perinatal Services of British Columbia. Registered Nurse Initiated Activities. Decision Support Tool No. 8A: obstetrical emergencies–cord prolapse. 2011. http://www.perinatalservicesbc.ca/ NR/rdonlyres/7682B7D8-166D-4990-86E4AC68B9F16066/0/CoreCompDSTOBEmergCord Prolapse8A.pdf. 8. American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists (ACOG). Guidelines for Perinatal Care. 7th ed. Washington, DC: ACOG; Elk Grove Village, IL: AAP; 2012. 9. Simpson KR. Perinatal patient safety and professional liability issues. In: Simpson KR, Creehan PA, eds. Perinatal Nursing. 4th ed. Philadelphia, PA: AWHONN with Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014. 10. American College of Obstetricians and Gynecologists Committee on Patient Safety and Quality Improvement. Committee opinion no. 590: preparing for clinical emergencies in obstetrics and gynecology. Obstet Gynecol. 2014; 123(3):722-725. Mary Dahl Maher is an associate professor of nursing at Nazareth College in Rochester, N.Y., and Elizabeth Heavey is an associate professor of nursing at The College at Brockport, State University of New York, in Brockport, N.Y. Dr. Heavey is also a member of the Nursing2015 editorial board. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NURSE.0000466449.65548.4a
56 l Nursing2015 l July
www.Nursing2015.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Pregn ancy in cri sis
Umbilical cord prolapse By Mary Dahl Maher, PhD, MPH, RN, CNM, and Elizabeth Heavey, PhD, RN, CNM
Occult umbilical cord prolapse
Overt umbilical cord prolapse
Visiting her mother at the hospital, VG, age 32, was a gravida 3, para 2 at 38 weeks’ gestation. (See Quick guide to pregnancy-related terminology.) As she was riding in the elevator, she experienced a sudden gush of clear fluid and felt something slippery between her legs. She stopped the elevator at the labor and delivery unit and explained to the receptionist what had just happened. The triage nurse had VG get into a bed and quickly removed her jeans to find a 3-in (7.6 cm) loop of coiled, pulsating umbilical cord with no meconium staining at the vaginal introitus. VG was experiencing an umbilical cord prolapse (UCP). This article describes the nurse’s vital role in the management of this obstetric emergency.
July l Nursing2015 l 53
www.Nursing2015.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Rare but urgent A UCP occurs when the fetal umbilical cord enters the birth canal before or alongside the presenting part of the baby. This rare obstetric emergency requires immediate intervention and a collaborative team response to help the infant survive. UCP is described as overt when the cord is palpated in the vagina or seen on the perineum following rupture of membranes; it’s described as occult when the cord isn’t visible but has descended next to but not past the presenting part. A UCP may be suspected when sudden prolonged fetal bradycardia is accompanied by moderate-tosevere variable decelerations, particularly when this change in the fetal heart rate (FHR) occurs after rupture of membranes (ROM). Although UCP can occur spontaneously, risk factors include iatrogenic causes, such as artificial ROM.1 (See What are the risk factors?) The incidence of UCP, estimated to affect 0.1% to 0.6% of total births, has remained constant over the last century.2 Fortunately, rates of fetal morbidity and mortality associated with this disorder have declined due to
The nurse or provider should place a gloved hand intravaginally to elevate the fetal presenting part off the cord. faster responses and improved surgical techniques. The triage nurse called for help and proceeded to elevate VG’s hips by placing the patient in a Trendelenburg position. The nurse began to perform a vaginal exam. As she applied manual pressure to the vertex, she found the
Quick guide to pregnancy-related terminology • Gravida. The number of pregnancies a woman has had. • Para. The number of live births a woman has had. • Multipara. A woman who’s had multiple live births. • Fetal heart rate (FHR) decelerations. When the FHR drops below the established baseline. • Tocolysis. Slowing or inhibiting labor contractions. • Vertex. Cephalic presentation; this means the fetal head enters the pelvis first. • Meconium. The first greenish stool passed by an infant. Its presence at a delivery may indicate fetal maturity or fetal distress. • Cervical status assessment: – Dilation. Measurement of cervical opening at the base of the uterus (10 cm is considered fully dilated). – Effacement. The process of cervical softening and shortening as the tissue thins out to facilitate passage of the fetal head through the cervix (0% to 100%). – Station. The relationship of the presenting fetal part (usually the head) to the ischial spines (0 station), measured in centimeters from –5 above (negative station) to +5 below (positive station).
cervix to be 4 cm (1.6 in) dilated, 70% effaced, and the vertex at −3 station with clear amniotic fluid. During the exam, a second RN arrived to assist, auscultated the FHR at 124 (normal baseline range, 110 to 160), and notified the attending obstetrician and the OR team to prepare for an emergency cesarean section. The triage nurse explained to a distraught VG the implications of her findings and why she’d need to maintain intravaginal manual pressure to keep the vertex lifted off the umbilical cord.3 In a supportive but directive manner, the triage nurse obtained a focused health history, while the second nurse provided supplemental oxygen, obtained peripheral venous access, started an I.V. infusion of lactated Ringer solution at 150 mL/hr, and drew blood specimens for lab work as prescribed (complete blood cell [CBC] count and type and screen). Assessment findings for VG included temperature 97.8° F (36.6° C), pulse 88, respirations 20, and BP 146/68. VG reported she’d last eaten yogurt and a banana for breakfast 3 hours before. The unit secretary retrieved the patient’s prenatal record and contacted VG’s husband. Nursing management: Emergency response The triage nurse should tell the patient what’s happening, providing clear information with emotional support, and call for assistance while beginning immediate interventions to prevent cord compression, which could result in fetal hypoxia. The patient’s hips should be elevated using a modified Sims, Trendelenburg, or knee-chest position. The nurse or provider should place a gloved hand intravaginally to elevate the fetal presenting part off the cord and be prepared to maintain this intervention until delivery.1 Minimizing direct handling or manipulation of the cord is extremely important because it can lead to vasospasm and fetal hypoxia. If the
54 l Nursing2015 l July
www.Nursing2015.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
umbilical cord is overtly prolapsed and transfer of the patient is needed, the cord can be gently replaced into the vagina and warmed sterile saline gauze can be applied at the introitus. The FHR should be auscultated, and continuous electronic fetal monitoring initiated. Oxygen should be delivered by mask at 8 to 10 L/min to promote fetal oxygenation and improve uteroplacental blood flow.3 As soon as possible, peripheral venous access should be obtained for fluid administration (the fluid will depend on provider preference and timing will depend on the timeframe to delivery); blood specimens obtained for CBC count, type, and Rh factor; and the mother prepared for cesarean delivery.1 The senior obstetric resident obtained informed consent from VG to proceed with a cesarean section. The FHR on an external fetal monitor ranged between 118 bpm and 134 bpm, with an occasional variable to 100 bpm. Eighteen minutes after her arrival on the unit, VG was wheeled into the OR with the triage nurse riding alongside her on the bed, still using her hand to apply pressure to the fetal head to keep it from pressing on the umbilical cord. In cases of UCP when delivery appears imminent, it’s possible to encourage the mother in pushing efforts while preparing for cesarean section as long as the FHR isn’t severely compromised.1 However, in this case scenario, spontaneous ROM occurred before the mother was aware of any contractions and her cervical exam was consistent with that of a multipara in early labor, so the patient didn’t have an urge to push and delivery wasn’t imminent. An urgent surgical delivery was indicated. The decision regarding anesthesia is based on many factors, including patient preference, medical status, and contraindications.4 Depending on the patient’s status and the hospital
What are the risk factors?1 Fetal features • Fetal malpresentation (nonvertex fetal presentation) • Unengaged vertex • Congenital anomalies • Prematurity • Small for gestational age Maternal pregnancy-related factors • Multiple gestation • Multiparity • Polyhydramnios—abnormally increased amniotic fluid • Spontaneous ROM Iatrogenic issues • Amniotomy—artificial ROM, when the provider intentionally ruptures the amniotic sac to release the amniotic fluid, sometimes done to speed up labor • Amnioinfusion—instilling fluid into the amniotic cavity • Manual rotation of the fetal head or other obstetric manipulation • External cephalic version—manually rotating a breech fetus to a vertex presentation • Placement of the cervical ripening balloon—a catheter placed into the cervix and filled with saline, which applies pressure to the cervix and promotes dilation and effacement for nonpharmacologic labor induction • Placement of an intrauterine pressure catheter or fetal scalp electrode.
setting, a cesarean section is usually performed under general anesthesia. However, if the FHR is stable with the mother in a knee-chest position, spinal anesthesia may be preferred because fewer maternal risks are associated with it.5,6 VG said she wanted to attempt spinal anesthesia rather than general anesthesia as long as the baby was stable. External fetal monitoring revealed the FHR to be stable, ranging between 120 bpm and 140 bpm with an occasional variable to 90 bpm. After VG was wheeled to the OR, the attending obstetrician directed the triage nurse to remove her hand after the patient was repositioned into a kneechest position. Continuous external fetal monitoring was maintained while the anesthesiologist administered spinal anesthesia. VG was transferred to the OR table with the FHR at 116 bpm to 128 bpm. A low transverse incision was made 35 minutes after the patient presented
to the receptionist. A female infant was delivered; her Apgar scores were 8 at 1 minute and 9 at 5 minutes. (See Understanding Apgar scores.) At 6 lb 4 oz (2.8 kg), she weighed almost 2 lb (0.9 kg) less than her two older brothers did at birth. VG’s husband arrived at the OR shortly after the birth and supported VG for the remainder of the surgical repair. The immediate postpartum period was uncomplicated, and the baby was put skin-to-skin in the recovery room. She successfully latched on the breast for the initial feeding. Documentation pointers In an emergency situation, be sure to identify a team member who’s responsible for maintaining a detailed record of maternal-fetal status, interventions, and response. Such items should include the following: • time of UCP • condition of the cord (color, pulsation, overall character) July l Nursing2015 l 55
www.Nursing2015.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
• notification of the obstetrician • the timing, sequence, and outcomes of nursing interventions, such as maternal positioning and administration of I.V. fluids and oxygen • fetal response to manual elevation of the presenting part to alleviate cord compression • obstetrician arrival time • type of anesthesia • the maternal and newborn status postinterventions.7 When rapid response is delayed With the increasing availability of rapid response with access to surgical delivery, optimal newborn outcomes in emergency situations, such as outlined in this case, have increased. Guidelines recommend that all hospitals be capable of beginning a cesarean section within 30 minutes of the decision to operate.8 The time to actual delivery and mode of delivery chosen should be based on the timing that best incorporates maternal and fetal risks and benefits.3
In cases where immediate surgical delivery isn’t possible, other interventions have been suggested in the literature. Bladder filling involves inserting a urinary catheter into the bladder, filling the bladder with 500 to 700 mL of 0.9% sodium chloride solution, and clamping; the idea is that the full bladder will push the presenting part upward and relieve cord compression. Tocolysis may be helpful if fetal distress is present. Sterile gauze saturated with sterile saline may be used to prevent the cord from drying out.1 Implications for team training In caring for a patient like VG, one of the RN’s primary responsibilities is to ensure a safe environment in which the patient can labor and give birth. This requires effective leadership, a shared family-centered philosophy, interprofessional collaboration, and excellence in key clinical practices.6,9 The efficiency and effectiveness of an emergency response can be greatly
Understanding Apgar scores The Apgar score is used for a rapid standardized assessment of an infant’s initial status after delivery and early in the neonatal transition period. The score is calculated at 1 minute after birth and repeated at 5 minutes after birth. Five measures are assessed and scored 0, 1, or 2 points each and then totaled. A 5-minute Apgar score of 7 or greater is considered normal. Most healthy infants won’t have an Apgar score of 10 because acrocyanosis, or blue discoloration of the hands and feet, is a normal observation in a healthy infant. If the 5-minute Apgar score is less than 7, it’s recommended that the infant continue to be assessed and the score recalculated every 5 minutes for up to 20 minutes. The Apgar score isn’t a predictor of future health status; rather, it’s an assessment of initial infant status. Points
0
1
2
Respiratory effort
None
Weak cry, Strong cry; rate and effort of hypoventilation breathing are normal
Heart rate
None
100 bpm
Muscle tone
Limp
Some flexion
Active motion
Reflex irritability
None
Grimace
Cry or active withdrawal
Color
Pallor or cyanosis Acrocyanosis
Normal
Source: Adapted from ACOG (2006, reaffirmed 2010). Committee Opinion #333: The Apgar score. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co333.pdf?dmc= 1&ts=20141206T0645151146.
enhanced by interprofessional education. Healthcare simulation and experiential training can help prepare staff to respond effectively to rare but lifethreatening situations.10 Interprofessional teamwork is a critical aspect of providing high-quality care during obstetric emergencies.10 ■ REFERENCES 1. Holbrook BD, Phelan ST. Umbilical cord prolapse: a plan for an OB emergency. Contemp OB/GYN. 2013;58(9):30-36. 2. Lin MG. Umbilical cord prolapse. Obstet Gynecol Surv. 2006;61(4):269-277. 3. American College of Obstetricians and Gynecologists. Practice bulletin no. 116: management of intrapartum fetal heart rate tracings. Obstet Gyencol. 2010;116(5):1232-1240. Reaffirmed 2013. 4. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. ACOG committee opinion. No. 339: Analgesia and cesarean delivery rates. Obstet Gynecol. 2006;107(6):1487-1488. Reaffirmed 2013. 5. Ginosar Y, Weiniger C, Elchalal U, Davidson E. Emergency Cesarean delivery for umbilical cord prolapse: the head-down, knee-chest prone position for spinal anesthesia. Can J Anaesth. 2008;55(9): 612-615. 6. Chebsey CS, Fox R, Draycott TJ, Sissakos D, Winter C. Umbilical Cord Prolapse. 2nd ed. GreenTop Guideline No. 50. London, UK: Royal College of Obstetricians and Gynaecologists; 2014. 7. Perinatal Services of British Columbia. Registered Nurse Initiated Activities. Decision Support Tool No. 8A: obstetrical emergencies–cord prolapse. 2011. http://www.perinatalservicesbc.ca/ NR/rdonlyres/7682B7D8-166D-4990-86E4AC68B9F16066/0/CoreCompDSTOBEmergCord Prolapse8A.pdf. 8. American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists (ACOG). Guidelines for Perinatal Care. 7th ed. Washington, DC: ACOG; Elk Grove Village, IL: AAP; 2012. 9. Simpson KR. Perinatal patient safety and professional liability issues. In: Simpson KR, Creehan PA, eds. Perinatal Nursing. 4th ed. Philadelphia, PA: AWHONN with Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014. 10. American College of Obstetricians and Gynecologists Committee on Patient Safety and Quality Improvement. Committee opinion no. 590: preparing for clinical emergencies in obstetrics and gynecology. Obstet Gynecol. 2014; 123(3):722-725. Mary Dahl Maher is an associate professor of nursing at Nazareth College in Rochester, N.Y., and Elizabeth Heavey is an associate professor of nursing at The College at Brockport, State University of New York, in Brockport, N.Y. Dr. Heavey is also a member of the Nursing2015 editorial board. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NURSE.0000466449.65548.4a
56 l Nursing2015 l July
www.Nursing2015.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
