Intrapartal Nursing Assessment

Linda L. Franco RN MSN NE-BCGreen = Need to Know

Red = Important to knowBlue = History

Maternal Assessment• History– List p 399

• Intrapartal High-Risk Screening– Table 18 -1

• Intrapartal Physical and Psychosociocultural Assessment– Assessment Guide p 403 -408

Determination of Due Date

• EDC or EDB (estimated date of confinement or birth)

• Evaluative tools – uterine size (single most important clinical way to measure the due date), fundal height (less accurate in late pregnancy), quickening (just now starting to feel the baby usually b/w 16-22 weeks) and fetal heart rate (avg detected about 8-12 weeks on ultrasound)

• Nagele’s Rule – the first day of the last menstrual period, subtract 3 months, and add 7 days.

Measuring Fundal Height

Assessment of Pelvic Adequacy

• Pelvic inlet measurement is made from the distance from the lower posterior border of the symphysis pubis to the sacral promontory, at least 11.5 cm

• Pelvic outlet – anteroposterior diameter, 9.5 to 11.5 cm. Transverse diameter, 8 – 10 cm.

• The pelvis can be assess vaginally to see if it’s adequate to have vaginal birth. Don’t perform on a woman with bleeding!

Intrapartal Nursing Assessment

• Maternal Assessment– Evaluating labor progress– Electronic monitoring of contractions– Cervical assessment

• Fetal Assessment– Position– Fetal heart rate– Periodic changes (in fetal HR)– If you see baby poo in the vaginal secretions that

means the baby is in distress, might be fetal hypoxia

Contraction Assessment• Palpation

– Frequency – Duration– Intensity

• By feeling the hardness of the fundus, soft like your nose or hard like your forhead

– Places one hand on the uterine fundus, note the time from beginning of one to the beginning of the next contraction.

• Electronic Monitoring of Contractions– External

• Positioned against fundus and held with elastic belt. Doesn’t accurately recorded the intensity

– Internal • IUPC (intrauterine something catheter) membrane must be ruptured and

dilated to at least 2 to use this guy

Intensity

Cervical Assessment• Dilatation

0 –10 cm

• Effacement0 – 100 %

• Station-3 to + 3Document how the membranes rupture, spontaneous

or by the dr? Document color and consistency of the amniotic fluid (needs to be clear)

Leopold’s Manuever

Leopold’s Manuever

Auscultation of Fetal Heart Rate

• FHR – heard most clearly at fetal back, put toco (sp? External device thing) on it’s back– Cephalic • Lower quadrants

– Breech• Upper quadrants

– Transverse Lie• Umbilicus

Electronic Monitoring of FHR

• External– Ultrasound

• Internal– Fetal Scalp Electrode

Fetal Heart Rates

• Baseline rate (need a baseline of at least 2 mins long)– Normal range 110 – 160

• Tachycardia – above 160– Reasons for this are: Early hypoxia, maternal fever and/or dehydration,

drugs with cardiac stimulant effects, amnionitis, maternal hyperthyroidism, fetal anemia, tachydysrhythmias

• Bradycardia – below 110– Late fetal hypoxia, maternal hypotension, umbilical cord compression,

fetal arrhythmia, uterine hyperstimulation, abruptio placentae, uterine rupture,vagal stimulation

– Meconium (sp?) strain, decreases FHR must report to a dr immediately

Variability• Short-term – beat to beat• Long-term – rhythmic fluctuations of the entire strip

• Absent – undetectable• Minimal – amplitude < 5 bpm• Moderate – amplitude 6 – 25 bpm• Marked – amplitude > 25

Variability con.• Decreased– Hypoxia, CNS depressant drugs, fetal sleep cycle,

fetus less than 32 weeks, fetal dysrhythmias, fetal anomalies, previous neurological insult, tachycardia

• Increased– Early mild hypoxia, fetal stimulation, alteration in

placental blood flow

Periodic Changes• Accelerations – transient increases in the fetal

heart rate, usually with fetal movement. Thought to be a sign of fetal well being and adequate oxygen reserves

• Decelerations (as long as it comes right back up we’re good)– Early– Late– Variable

Early Decelerations• Onset occurs before the onset of the

contraction• Uniform in shape• Caused from fetal head compression– Baby is being squeezed…

• Does not require intervention– This is normal

Late Decelerations

• Onset occurs after the onset of the contraction

• Uniform in shape• Caused from uteroplacental insufficiency– For some reason the uterus isn’t getting the

oxygen it needs• Nonreassuring but does not necessarily

require immediate delivery

Variable Decelerations• Onset varies with timing of the onset of the

contraction• Variable in shape• Caused from umbilical cord compression– Thus reducing blood flow b/w the placenta and

the fetus– Causes fetal HTN, causes the baby’s HR to go

down• Requires further assessment

Nursing Interventions• Oxygen via facemask• Discontinue Pitocin infusion

– If they are getting it… this drip makes their uterus clamp down tight and we need to stop that

• Turn patient to left side or knee chest• Notify physician• Hydrate patient

– Maybe turn up the IV fluid• Administer Tocolytics

– These are used to slow down contractions or stop them, Magnesium sulfate, prostaglandins, calcium channel blockers, brethine

– Can cause maternal side effects like maternal pulmonary edema

Fetal Blood Sampling• Fetal Scalp Stimulation Test

• Umbilical Cord Blood Sampling

• Normal pH 7.20 – 7.25

• Fetal Oxygen Saturation Monitoring