GOVERNMENT COLLEGE OF NURSING

JODHPUR

CARE PLAN
ON
CORD PROLAPSE

SUBMITTED TO: SUBMITTED BY:

MRS. JYOTIBALA JANGID PRIYANKA GEHLOT
LECTURER M.Sc. (N) FINAL
IDENTIFICATION DATA:
Name - Mrs.Radha

Age - 25 years

Sex - Female

Religion Hindu

I.P.D. NO - 546783

Education -10thstandered

Marital status - Married

Address - Kudi Housing Board,Jodhpur

Occupation - Housewife

Date of admission - 12/08/21

Obstetrical score -G2 P1 L1 A0

Diagnosis - Umbilical Cord prolapsed

OBSTETRICAL HISTORY:

Mrs.Radha has 4 years of active married life. She conceived for the first time and carried the pregnancy to full term and delivered a female baby weighing 2.7 kg.
Now she is pregnant for the second time with full term gestation. Therefore she is G2 P1 L1 A0.
PRESENT MEDICAL HISTORY-
At present the client is suffering from Umbilical Cord prolapsed.

PRESENT SURGICAL HISTORY-

There is no present surgical history.
PAST MEDICAL HISTORY-
She doesn’t have any significant medical illness even in her previous pregnancy. She has taken two doses of injection TT during her pregnancy period. She does
not have any drug allergies.
PAST SURGICAL HISTORY-
She does not have any gynecological or other operation in the past.
MENSTRUAL HISTORY: -

She attended her puberty at the age of 13 years. She did not have any history of dysmenorrhea or irregularity of the menstrual cycle.

NUTRITIONAL HISTORY: -

She is a non-vegetarian. She takes two meals a day. She takes rice, ragi, maize, pulses, etc. She does not have any food allergy. She does not have any history of
malnutrition.

FAMILY HISTORY-
There is no communicable disease in the family. All family members are healthy.
TYPE OF THE FAMILY:
She is living in a nuclear family. She is living with her husband. All her family members do not have any hereditary or communicable diseases. They do not have
medical or surgical history even.

FAMILY COMPOSITION-

S.l Name relationship Age Sex Educatio occupatio Marit Health

. with the n n al status
no patient status
1 Mr.Sunil Husband 27yea Male 10th class Auto Good Healthy
r Driver

2. Mrs.Radha Self 25yea Female 8th class Housewife Good Umbilical

r cord
prolapsed

3. Baby Daughter 3year Female Nil Nil - -

FAMILY TREE-

KEYS-

Male =

Female =

Client =
SOCIO- ECONOMIC AND CULTURAL BACKGROUND:

Mrs. Kanika ‘s husband is only single earning of the family and she is a housewife. There is adequate water supply and electricity facility in their house. They
practice closed drainage system. There is adequate ventilation in the surrounding environment. They maintain good interpersonal relationship with the neighbors.

PHYSICAL EXAMINATION

General appearance:

She is well nourished and has a moderate body built. She is groomed neatly but she looks anxious.

Posture –

She has an erect body. She does not have any abnormal body curvature like lordosis, kyphosis or scoliosis.

Skin–

She has a normal skin color. There is presence of no macules, papules, vesicles or skin rashes, etc.

Head and face:

Her hair is black in color. It is thin and smooth in texture. The scalp is clean and clear. Her face looks anxious.

Eyes:

Her eyebrows are symmetrically present; there is equal distribution of eyelashes. Eyelids are free of infection or sty; the conjunctiva is pink in color. Sclera is
transparent in nature. The pupils are equally reacted to light and her vision capacity is adequate.

Nose:
It is normal in shape and structure. The nostril is clean and it is free of discharges and crust collection. Both the nostrils are symmetrical in opening as equally
divided by the nasal septum.

Ears:

The external ears are normal in shape and structure. There free of discharges, cerumen collection or the perforation of the tympanic membrane and infection in the
internal ear.

Mouth:

The lips are smooth, the teeth are white in colour and they are free of dental carries. The gum is pink in colour and it’s free from swelling and bleeding. The tongue
is pink in colour, moist. The tonsils are free from infection.

Neck:

During inspection there is no enlargement of the thyroid gland and all the range of movement are possible without causing any pain. There is no enlargement of the
lymph node during palpation.

Chest:

On inspection - There is symmetrical expansion of the thorax and she has a normal breathing pattern.

On auscultation - There is no abnormal breath sound like whistling sound, rale or crackle sound, etc. While doing examination there is no abnormal heart sound
like cardiac murmur.

Breast:

Both breasts are symmetrical. Nipples are erect, there are no cracks;there is no abnormal lump palpable.

Obstetrical examination

Inspection- The abdomen is globular due to gravid uterus, striae gravida, linea nigra is found to be present. The umbilicus is transversely stretched.
Palpation -Fundal palpation soft mass is palpated as for the signs for the presence of breech, the fundal height is measured as 36cms.

In right lateral palpation regular nodes felt as for the presence of spine or the back and in the left lateral palpation irregular mass is palpated for the presence of
limbs. During the pelvic grip I soft mass is felt for the presence of buttock.

Auscultation- The fetal heart sound is noted to be 132 beats per minute. The abdominal girth is 96 cm.

Genitalia:

Cord palpable on vaginal examination On Vaginal examination the bluish coloration of the vulva, vagina and cervix is present. Cervix is soft and comparatively
firm to touch. Regular and rhythmic uterine contractions are elicited during bimanual examination.

Extremities:

The extremities are free from edema or varicosities present. All the range of movement is performed by the mother without any difficulty.

MANAGEMENT OF CORD PROLAPSE

Management depends upon the foetal state:

TREATMENT:

• Assess & support maternal ABC’s

• Rapid transport

 To prevent fetal asphyxia, if the cord is visible or palpable in the vagina:

Position the mother with hips elevated as much as possible, OR in Trendelenburg position or in a knee-chest position.
Living foetus:

 Partially dilated cervix: Immediate caesarean section is indicated.

During preparing the theatre minimize the risk to the foetus by:

 putting the patient in Trendelenburg position,

 manual displacement of the presenting part higher up,

 If the cord protrudes from the vulva, handle it gently and wrap it in a warm moist pack.

 Giving oxygen to the mother.

Fully dilated cervix: the foetus should be delivered immediately as in cord presentation.

 Dead foetus:

– Spontaneous delivery is allowed.

– Caesarean section: is the safest. Procedure in obstructed labour as destructive operations are out of modern obstetric.

Management of fetal distress during labour

 Conservative:

 Stop oxytocin drip: if it is in use.

 Left lateral position of the mother: to relieve aorto-caval compression to s improves uteroplacental blood flow.

 Oxygen: is given by mask to the mother in a rate of 6 liters / min. increases the O2 supply to the foetus.

 Immediate delivery: is indicated if the foetal distress is not improved by the conservative methods. This is achieved by:
  Vacuum extraction, forceps delivery or breech extraction: if the cervix is fully dilated and vaginal delivery is amenable.

 Caesarean section: if rapid vaginal delivery is not amenable.

NURSING DIAGNOSIS:-

1. Risk for fetal injury related to cord compression.

2. Risk for intrauterine infection related to exposure of externally prolapsed cord to perineal area.
3. Fear related to fetal outcome.
Assessment Nursing Goal Nursing intervention Implementation Evaluation
diagnosis
Objective data: Risk for fetal The patient -Monitor fetal presentation and position. -Monitored fetal The fetal condition
On examination injury related to will -Monitor FHR and electronic tracings presentation, it is breech (FHR) is improved and
umbilical cord cord experience throughout labour, presentation. there is no further fetal
is visible in the compression. no fetal -Call for assistance -Monitored the FHR and injury.
vaginal injury. -Perform sterile vaginal examination. electronic tracings
introitus. -Move the presenting part off the cord. throughout labour,
-Place the patient in knee chest position. -Called for the assistance.
-Support her with pillows. -Performed sterile vaginal
-Administer oxygen by mask at a rate of 8 examination.
to 10 l/min. -Placed the patient in
-Do not reinsert the externally prolapsed trendelenberg position.
umbilical cord. -Administered oxygen.
-Apply warm sterile saline solution -Reinsertion of cord is not
compresses to the umbilical cord. done.
-Do not administer oxytocin -Applied warm sterile
-Prepare for cesarean birth. saline.
-Oxytocin is not
administered.
-Preparation is done for
cesearean.
 Risk for The patient -Do not reinsert the umbilical cord. -Reinsertion is not done. The patient exhibit no
intrauterine will exhibit -Completely cover the protruding cord with signs of infection.
infection related no signs of a warm sterile saline solution dressing or
to exposure of infection. perineal pad. -The protruding cord is
externally covered with a warm sterile
prolapsed cord solution.
to perineal area.

Subjective Fear related to The patient -Calmly explain the procedure. -Calmly explained the The patient express less
data- fetal outcome. will express -Provide a quiet and calm environment. procedure. fear
The client less fear. -Explain the condition of the baby to the -Provided a quiet and calm
complaint that mother. environment.
she is having -Explained the condition of
fear about the the baby to the mother.
fetal outcome.
Objective data-
The nurse
observe that
client has
anxiety ,fear.
HEALTH EDUCATION-

Promote Comfort:

 Patient is advised to take left lateral position & use pillows to promote comfort.
 Teach patient to maintain personal hygiene regularly
Promote circulation:

 Instruct client for turning, deep breathing exercises.

 Encourage for leg & feet exercises while in bed.
 Encourage the client for frequent & short ambulation.
 Advise client to sit by raising legs on table and chair
 Encourage client to have good ventilation in room.
 Encourage patient to avoid strenuous activities and heavy workload such as washing cloths climbing up stairs etc.
Maintain fluid & electrolyte balance:

 Encourage the client to void every 2 hourly.

 Advise the patient to take more fluids.
Maintain normal elimination pattern:

 Educate patient about regular perineal care.

 Encourage client for early ambulation.
 Educate client about signs of UTI.
 Encourage patient to take roughage rich diet such as salad ,fruits such as apple ,grapes ,dalia ,fluids etc to avoid constipation.
 Perform range of motion exercises but avoid strenuous activities.
Diet:

 Encourage client to take nutritious diet & more fluids .

  Encourage client to take iron rich diet i.e. green leafy vegetables, jaggery etc.
 Encourage client to take zinc rich diet i.e. spinach.
 Encourage the client to take juices and fruits which contains vitamin c i.e. helpful for enhancing the absorption of iron
 Encourage client to take roughage rich diet such as fruit,salad,dalia etc.
Others:

 Meditation.
 Avoid heavy work.
 Refrain from coitus till last trimester.
 Teach the patient about family planning methods