Intrapartal Nursing Assessment

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Intrapartal Nursing Assessment
- Tie everything together

• Linda L. Franco RN MSN NE-BC

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Maternal Assessment

• History
• List p 399
• Intrapartal High-Risk Screening
• Table 18 -1
• Intrapartal Physical and Psychosociocultural
  Assessment
• Assessment Guide p 403 -408

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Determination of Due Date

• EDC or EDB (estimated date of confinement or
  birth)
• Evaluative tools uterine size, Fundal height,
  quickening and fetal heart rate (FHR 8-12wk
  gestation by US)
• Nageles Rule the first day of the last
  menstrual period, subtract 3 months, and add 7
  days.

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Measuring Fundal Height
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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.
• Never to be preformed on a mother that is
  bleeding else risk of perforation.

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Intrapartal Nursing Assessment

• Maternal Assessment
• Evaluating labor progress
• Electronic monitoring of contractions
• Cervical assessment
• If membranes ruptured and meconium is noted, then
  the nurse must perform a vaginal exam to check
  for cord prolapse. Meconium in the amniotic
  fluid usually indicates fetal distress and/or
  hypoxia. Cord prolapse is an emergency and
  requires C-Section.
• Define Meconium- a material that collects in the
  intestines of a fetus and forms the first stools
  of a newborn.
• Fetal Assessment
• Position
• Fetal heart rate
• Periodic changes
• Amniotic fluid loss ? fetal hypoxia
• May need emergency C-Section

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Contraction Assessment

• Palpation
• Frequency-
• Duration
• Intensity
• Electronic Monitoring of Contractions
• External (TOCO) electronic device belt that
  monitors and records uterine contractions.
• Internal Cervix must be dilated to at least 2
  (Fetal Scalp Electrode)

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Intensity
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Cervical Assessment pg 385

• Nurse will look for
• Dilatation
• 0 10 cm
• Effacement
• 0 100
• Station
• -3 to 3
• Caused by process of labor or by Phys?
• Amniotic must be clear

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Leopolds Maneuver pg413 and pg 415
Mother must 1st empty bladder
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Leopolds Manuever
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Auscultation of Fetal Heart Rate pg 413

• FHR heard most clearly at fetal back
• Cephalic
• Lower quadrants
• Breech
• Upper quadrants
• Transverse Lie
• Umbilicus

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Electronic Monitoring of FHR

• External
• Ultrasound
• Internal
• Fetal Scalp Electrode

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Fetal Heart Rates pg418-420

• Baseline rate (Important to find median needs be
  at least 2min long)
• Normal range 110 160
• Tachycardia above 160
• Early hypoxia, maternal fever and/or dehydration,
  drugs with cardiac stimulant effects, amnionitis
  itis of outer surface of umbilical cord,
  maternal hyperthyroidism, fetal anemia,
  tachydysrhythmias
• Bradycardia below 110
• Late fetal hypoxia, maternal hypotension,
  umbilical cord compression, fetal arrhythmia,
  uterine hyperstimulation, abruptio placentae
  separation of the placenta, uterine rupture,
  vagal stimulation
• Any abnormalities must be passed to Phys
  immediately

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Variability Fig 18-?

• Short-term beat to beat
• Long-term rhythmic fluctuations of the entire
  strip
• Absent undetectable
• Minimal amplitude lt 5 bpm
• Moderate amplitude 6 25 bpm
• Marked amplitude gt 25

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Variability con. Pg 421-2

• Decreased/reduced
• Hypoxia, CNS depressant drugs, fetal sleep cycle,
  fetus less than 32 weeks, fetal dysrhythmias,
  fetal anomalies, previous neurological insult,
  tachycardia
• Increased/marked
• Early mild hypoxia, fetal stimulation, alteration
  in placental blood flow (may be able to lay
  mother Lt side to treat)

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Periodic Changes pg423-4

• Accelerations
• Incr in FHR due to fetal movement, sign of fetal
  well-being good.
• Decelerations
• Early- FHR goes down from being squeezed
  (Normal), happens right before the contractions
• Late- occurs after the contraction, caused by
  uterine/placental insufficiency. Administer
  oxygen.
• Variable

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Early Decelerations p424Its okay

• Onset occurs before the onset of the contraction
• Uniform in shape
• Caused from fetal head compression
• Does not require intervention
• Lower moms head (suspine) or lay on lt side

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Late Decelerationsa little more concerning

• Onset occurs after the onset of the contraction
• Uniform in shape
• Caused from uteroplacental insufficiency
• Nonreassuring but does not necessarily require
  immediate delivery
• Reqs continuous assessment

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Variable DecelerationsIntervention ASAP

• Onset varies with timing of the onset of the
  contraction
• Variable in shape
• Caused from umbilical cord compression
• Requires further assessment

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Nursing Interventions

• Oxygen via facemask
• Discontinue Pitocin to stimulate contractions
  infusion
• Turn patient to left side or knee chest
• Notify physician
• Hydrate patient
• Administer Tocolytics- meds to slow down
  contractions (MagSulfate, Prostaglandin, CCB,
  Breathine)

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Fetal Blood Sampling pg427

• Fetal Scalp Stimulation Test
• Umbilical Cord Blood Sampling
• If fetus was distressed or APGAR score lt7)
• Normal pH 7.20 7.25
• Fetal Oxygen Saturation Monitoring