Intrapartal Nursing Assessment

1
Intrapartal Nursing Assessment

• Linda L. Franco RN MSN NE-BC
• Green Need to Know
• Red Important to know
• Blue History

2
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 (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)
• Nageles Rule the first day of the last
  menstrual period, subtract 3 months, and add 7
  days.

4
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.
• The pelvis can be assess vaginally to see if its
  adequate to have vaginal birth. Dont perform on
  a woman with bleeding!

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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

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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. Doesnt accurately recorded the intensity
• Internal
• IUPC (intrauterine something catheter) membrane
  must be ruptured and dilated to at least 2 to use
  this guy

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Intensity
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Cervical Assessment

• Dilatation
• 0 10 cm
• Effacement
• 0 100
• Station
• -3 to 3
• Document how the membranes rupture, spontaneous
  or by the dr? Document color and consistency of
  the amniotic fluid (needs to be clear)

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Leopolds Manuever
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Leopolds Manuever
12
Auscultation of Fetal Heart Rate

• FHR heard most clearly at fetal back, put toco
  (sp? External device thing) on its 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

• 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

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Variability

• 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.

• 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

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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
  were good)
• Early
• Late
• Variable

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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

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Late Decelerations

• Onset occurs after the onset of the contraction
• Uniform in shape
• Caused from uteroplacental insufficiency
• For some reason the uterus isnt getting the
  oxygen it needs
• Nonreassuring but does not necessarily require
  immediate delivery

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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 babys HR to go down
• Requires further assessment

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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

22
Fetal Blood Sampling

• Fetal Scalp Stimulation Test
• Umbilical Cord Blood Sampling
• Normal pH 7.20 7.25
• Fetal Oxygen Saturation Monitoring