INTRAPARTAL NURSING ASSESSMENT

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INTRAPARTAL NURSING ASSESSMENT

• Chapter 18

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Maternal Assessment

• 1. History
• General health
• Medications
• Allergies
• Obstetrical
• Labor
• Birth plan

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Risk Assessment

• Bleeding
• Rom
• Hospitalizations
• Preterm labor
• PIH
• Diabetes
• Abnormal presentation

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Physical Assessment

• Admission Assessment
• Labor status
• Contraction pattern
• Cervical dilation and effacement
• Fetal descent
• Membranes
• Fetal status
• laboratory

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Fetal Assessment

• Assess fetal position
• Inspection
• Palpation Leopolds maneuvers
• Vaginal exam and ultrasound

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Fetal Heart Rate

• Tools
• Fetoscope
• Doppler
• EFM
• External or internal
• Baseline rate 120 to 160
• Abnormal Fetal Heart Rates
• Tachycardia sustained rate of 161 or above
• Marked 180 or above
• Causes
• Early Hypoxia Maternal Fever
• Dehydration Drugs
• Amniotitis Hyperthyroidism
• Fetal anemia

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Fetal Bradycardia

• Rate Less than 120 during a 10 minute period or
  longer
• Causes
• Late or severe fetal hypoxia
• Maternal Hypotension
• Prolonged umbilical cord compression
• Fetal arrhythmia

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Variability

• Short Term
• Long Term
• Absent
• decreased
• Average
• Increased
• Marked

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Decelerations

• Early
• Late
• Variable

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Non-Reassuring Patterns

• Severe variable decelerations or FHR drops below
  70 for longer than 30 to 45 seconds
• Late decelerations of any magnitude
• Absence of variability
• Prolonged decels that lasts 60-90 seconds or more
• Severe marked bradycardia of 70 or less

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Nursing management of Decelerations

• Turn mom to left side
• Administer O2 by face mask at 7-10 L
• Discontinue oxytocin
• Increase IV fluids
• Assess labor progress by SVE
• Notify physician
• Monitor VS and stay with pt.

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• Scalp Stimulation
• Fetal scalp blood sampling

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