lOMoARcPSD|6828319

Chapter 18 Intrapartum Nursing Assessment

Concepts Of Maternal-Child Nursing And Families (Nova Southeastern University)

StuDocu is not sponsored or endorsed by any college or university

Downloaded by Frida Grillo (cigcna@gmail.com)
 lOMoARcPSD|6828319

INTRAPARTUM NURSING ASSESSMENT

Maternal Assessment
History • Woman’s age, last menstrual period, and estimated
date of birth
• Personal data: blood type, Rh factor, weight present
and before pregnancy, allergies, meds taken during
pregnancy
• Hx of drugs, smoking and alcohol use during
pregnancy
• Hx of previous illness: heart disease, DM, TB
Physcosocial • Mothers may fear having a bowel movement during the
Consideration second stage of labor and may be embarrassed
• Concerned about labor will be like
• Physical and emotional stress of birth
• It is important for mother to realize that pain of labor is
natural
• Provide positive reinforcement that mother is doing a
great job
• Some woman may have depressive disorders during
pregnancy
• Some women may be diagnosed with mental illnesses
that may impact the labor and birth processes:
o Eating disorders, autism, learning disabilities,
attention deficit, anxiety and mood disorders
• Prenatal period problems: increased BP, bleeding,
recurrent UTI
• Gravida, para, abortions, prenatal deaths
• Method chosen for infant feeding
• Woman’s preference to labor and delivery
• Hx of NST, BPP, US, Hx of preterm labor, onset of labor
• Status of amniotic membranes (are they ruptured? If so,
ask color, odor)
• Assess women with mental illnesses during pregnancy
and after pregnancy
• Ask questions about domestic violence, sex abuse
during pregnancy.
• Some medications can cause fetal issues such as Paxil,
which is known to cause cardiac anomalies

High-Risk Note the presence of any factors that may be associated with a high-risk condition
Screening • For example if a woman reports bleeding, this needs further assessment to rule out abruptio placentae or placenta
previa. Ask for amount of bleeding , onset, duration
• Teach patient that she should ever get a vaginal examination if bleeding is present
• Sociocultural variable may also increase risk: poverty, nutrition, degree of prenatal care received, cultural belief,
communication, social support, alcohol, tobacco and drug use and presence of PTSD

Physical & Assess body systems and actual labor process

Psycho- • When labor is progressing quickly, there may not be time for a complete nursing assessment
sociocultural • Critical physical assessment during labor are: pregnant history, high-risk factors/problems that occurred during
Assessment pregnancy, maternal vital signs, labor status, fetal status and lab findings
• Cultural assessment
• Assess psychosocial factors so that the nurse can meet the woman’s needs for info and support
• While performing the intrapartum assessment, it is crucial to follow the CDC’s guidelines to prevent exposure to body
substances
• Some woman may want the use of aromas for physical, mental and emotional healing (oils or lotions)

Contraction PALPATION ELECTRONIC MONITORING OF CONTRACTIONS

Assessment • Assess contractions for frequency, duration and • Provides continuous data
intensity by placing one hand on the uterine • Electronic monitoring can be done eternally with a device
Nurse fundus placed on the maternal abdomen
assesses the • Keep hand still bc excessive movement of the o Tocodyamometer – placed in the fundus, responds
woman’s nurses hand can stimulate contractions to pressure. When uterus contracts the change in
contractions • To determine contraction duration – note the pressure is amplified and transmitted to the monitor
and cervical time when tensing of the fundus is first felt o It does not accurately record the intensity of
(beginning of contraction) and again as contraction
dilation and
relaxation occurs (end of contraction) o It is difficult to obtain accurate FHR in women who
effacement
• During acme of the contraction, intensity can are obese, abnormal amount of amniotic fluid,
to evaluate
be evaluated by estimating the indentability of active fetus and premature cases of fetus
labor the fundus • Electronic monitoring can be done internally with an
progress • Assess at least three successive contractions to intrauterine pressure catheter
gain enough data to determine contraction o Accurate measurement of contraction intensity
pattern (the strength of contraction and the pressure
• Assess the woman’s pain, tell her to describe within the uterus
the pain o Catheter is only placed with the membrane has
ruptured

Downloaded by Frida Grillo (cigcna@gmail.com)

 lOMoARcPSD|6828319

External Electronic Fetal Heart Monitoring Internal, direct fetal monitoring

Cervical • Cervical dilation and effacement are evaluated directly by vaginal examination
Assessment • The vaginal examination provides info: membrane status, character of amniotic fluid, fetal position and station
• The nurse inserts the index and middle fingers against the cervix to determine the size of the opening
• During labor the cervix begins to dilate and the size of the opening progresses from 1 – 10 cm

Fetal Assessment
Fetal Fetal presentation and position are determined by inspecting the woman’s abdomen, palpating it, performing a vaginal
Position and examination and auscultating FHR
Presentation INSPECTION
• Observe the size and shape of the abdomen
• Assess the lie of the fetus by noting whether uterus projects up and down (longitudinal lie) or left to right (transverse)
PALPATION
• Leopold’s maneuvers – may be hard to perform on an obsess woman or on a woman with excessive amniotic fluid
• Before palpating woman need to empty the bladder and lie on her back with her feet knees bent
VAGINAL EXAM AND US
• During vaginal examination, examiner can palpate the presenting part if the cervix is dilated
• Provides information about the fetal position
• Ultrasound is done to visualize the fetal position when it cannot be determined by abdominal palpation
Auscultate • Doppler US is used to auscultate the FHR between, during • In a transverse lie, the FHR may be heard best just
FHR and immediately after uterine contractions above or just below the umbilicus
• Fetascopes – used to auscultate the FHR after 20 weeks • As the baby descends down the pelvis the FHR is
• The Leopold’s maneuver is perform first, before auscultating heard downward, midline
• The FHR is heard best heard clearly at the fetal back • WHEN FETAL FHR IS LOCATED IT IS COUNTED FOR
• If the fetus is in the cephalic presentation, the FHR is best 30 SECONDS AND MULTIPLIED BY 2 TO GET BPM
heard in the lower quadrant of the maternal abdomen • Check woman pulse against the fetal sounds
• In the breech position, the FHR is best heard at or above the • OCCASIONALLY LISTEN FOR A FULL MIN IF THE FHR
umbilicus IS OVER 160 BPM, UNDER 110 BMP OR IRREGULAR
• Listen to fetal heart rate during contraction and after
contraction
Electronic • Electronic fetal monitoring – produces continuous tracing of the • Internal monitoring requires an internal
Monitoring FHR which allows visual assessment of many FHR characteristics electrode thru the vagina.
Of FHR • When to monitor electronic FHR – previous Hx of stillbirth, o In order to get the monitor the amniotic
presence of complication of pregnancy (preeclampsia, placenta membranes must have ruptured, the
previa, abruptio placentae), induction of labor, premature cervix must be dilated at least 2 cm and
gestation, decreased fetal movement, nonreassuring fetal status presenting part should be known
• External monitoring - fetus is accompanied by a ultrasound o The electrode is attached to a fetal
• telemetry systems that can be placed in the woman monitor
o Provides more accurate data than
external monitoring
Variability Strip’s

Downloaded by Frida Grillo (cigcna@gmail.com)

 lOMoARcPSD|6828319

Fetal Heart • Baseline rate – normal FHR 110-160 beats/min, during • Baseline variability - interchange between
Rate at 10 min duration, baseline should no less than 2 mins sympathetic and parasympathetic system over 10
• Variability – change in the FHR over a few seconds to a mins. It reflects baseline fluctuations that are
few mins irregular in frequency and amplitude.
• Fetal tachycardia – sustained rate of 161 beats/min or • If an fetus has absent or minimal variability they are
above at high risk of acidosis and subsequent hypoxia
• Marked tachycardia is 180 bpm or above • Causes of reduced variability: hypoxia and acidosis,
• Causes of tachy: fetal hypoxia, maternal fever, drugs that depress the CNS, fetal sleep cycle
maternal dehydration, sympathetic drugs, intrauterine • Causes of marked variability: early mild hypoxia, fetal
infections, maternal hyperthyroidism, and fetal anemia stimulation, fetal breathing movements, stimulant
• Fetal bradycardia – rate less than 110 bpm during a 10 meds
min period or longer • Absent variability that does not appear to be
• Causes of brady: late fetal hypoxia, maternal associated with a fetal sleep cycle or meds is a
hypotension (less blood to fetus), umbilical cord warning sign!
compression, fetal arrhythmia, abruptio placentae, • External fetal monitoring is not adequate way to
uterine rupture, vagal stimulation, heart block and assess variability, internal monitor is more accurate
maternal hypothermia
Accelerations – the transient increases in the FHR (normally caused by Types of decelerations
fetal movement) • Early – occurs before the onset of uterine
• When fetus move heart rate increases contractions (considered benign and doesn’t
• Accelerations may accompany uterine contractions (due to fetal require intervention)
movements) • Late – caused by uteroplacental insufficiency
• Accelerations during contractions are a sign of fetal well-being resulting from decreased blood flow and O2. Late
Decelerations – decreases in FHR from normal baseline deceleration occurs after the onset of contraction.
• When the fetal head is compressed, cerebral blood flow is Late decelerations are considered a nonreassuring
decreased, which leads to central vagal stimulation and results in sign. If late decelerations continue and birth is not
early deceleration forthcoming, a C-section may be needed 
• Variable – occurs when the umbilical cord is
compressed, thus reduces blood flow between the
placenta and the fetus. The resulting increase in
peripheral resistance in the fetal circulation causes
fetal HTN. The fetal HTN stimulates the
baroreceptors which lowers the FHR
Nursing Management
• It is crucial that nurses balance technology with holistic nursing practice
• Before the nurse uses the electronic fetal monitoring, explain the reason for its use and the information it can provide
• Record basic information on the strip
• As the monitor strip runs should note down occurrences during labor such as: dilation, effacement, station, position, color and amount of
amniotic fluid and odor, maternal vital signs, maternal position, O2 administration, emesis, cough, hiccups, pushing and administration of
anesthesia blocks
• If monitor doesn’t automatically add the time on the strip at specific intervals, include the time on the strip
• If more than one nurse is adding info on the strip, make sure to initial each note on the strip
• Fetal monitor strip should be reviewed regularly (at least every 30 mins in the first stage and every 15 min in the 2 nd stage of labor)
• Evaluating the electronic monitor tracing by looking at the uterine contraction patterns:
o The nurse should determine the uterine resting tone and should assess the contractions frequency, duration and intensity
• Share information with mother to reassure that everything is ok

Scalp Used when there is a question about the fetal status, and is used before the more invasive fetal blood sampling
Stimulation • Examiner applies pressure in the fetal scalp while vaginal exam
Test • Fetus who is not in any stress or distress responds with an acceleration of the FRH
• Fetus that fails to respond have an increased incidence of acidosis, hypoxia and lower Apgar score
• Fetal heart rate accelerations in response are a sign of fetal well-being
• IF THERE IS NO FETAL REACTION TO THE SCALP STIMULATION TEST – nurse should contact MD
Cord Blood Done when practioner wishes to determine if acidosis is present
Analysis at • Indications for this exam are: meconium-stained amniotic fluid, abnormal FHR patterns, infant is depressed at birth and
Birth Apgar scores less than 7 at 5 mins of age
• The umbilical cord is clamped before the infant takes the first breath and a small amount of blood is aspirated with a
syringe from one of the umbilical arteries
• If the cord blood will not be analyzed STAT, then a heparinized syringe is used
• Normal fetal blood pH: above 7.25, lower levels indicate acidosis and hypoxia

Downloaded by Frida Grillo (cigcna@gmail.com)