Intrapartal Nursing Assessment

1. - Tie everything together Intrapartal Nursing Assessment Linda L. Franco RN MSN NE-BC

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

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

4. Measuring Fundal Height

5. 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.

6. 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

7. 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)

8. Intensity

9. 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

10. Mother must 1st empty bladder Leopold’s Maneuver pg413 and pg 415

11. Leopold’s Manuever

12. Auscultation of Fetal Heart Rate pg 413 • FHR – heard most clearly at fetal back • Cephalic • Lower quadrants • Breech • Upper quadrants • Transverse Lie • Umbilicus

13. Electronic Monitoring of FHR • External • Ultrasound • Internal • Fetal Scalp Electrode

14. 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

15. Variability Fig 18-? • 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

16. 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)

17. *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

18. Early Decelerations p424It’s okay • Onset occurs before the onset of the contraction • Uniform in shape • Caused from fetal head compression • Does not require intervention • Lower mom’s head (suspine) or lay on lt side

19. 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

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

21. 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)

22. Fetal Blood Sampling pg427 • Fetal Scalp Stimulation Test • Umbilical Cord Blood Sampling • If fetus was distressed or APGAR score <7) • Normal pH 7.20 – 7.25 • Fetal Oxygen Saturation Monitoring