Transcript Intrapartal Nursing Assessment copy

- Tie everything together
Intrapartal Nursing
Assessment
Sue Nesbitt, RN, MSN
Learning Outcomes
• Discuss the components of a maternal
assessment for a laboring client.
• Evaluate labor progress using contractions,
cervical dilatation, and effacement.
• Describe fetal assessment to identify fetal
position, presentation, heart rate, and fetal
status.
• Identify baseline and periodic change in fetal
heart rate, and their significance.
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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• The history is essentially a screening tool that identifies
factors that may place
• the mother or fetus at risk during the pregnancy.
• Intrapartal high-risk screening – risk factors are any findings
that suggest
• the pregnancy may have a negative outcome for the mother
or unborn fetus.
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.
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EDC or EDB is determined by knowing the date of the LMP. However, when
women have a history of irregular bleeding or fail to keep track of menstrua
l cycles, we resort to other evaluative tools. Uterine size may be the single
most important clinical method for dating her pregnancy. However, when
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women do not seek maternity care until well into their second trimester, it
becomes more difficult to determine the uterine size.
Fundal height may be used in early pregnancy (it is less accurate in late
pregnancy). A centimeter tape measure is used to measure the distance
abdominally from the top of the symphysis pubis to the top of the uterine
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fundus. Fundal height in centimeters correlates well with weeks of gestation
between 22 to 24 weeks and 34 weeks. Thus , at 26 weeks gestation, fundal
height is probably about 26 cm.
Quickening – (fetal movement) – may indicate the fetus is nearing 20 weeks
gestation. However, quickening may be experienced between 16 and 22 weeks Gestation.
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Fetal Heart Rate –Fetal heartbeat can be detected, on average,
at 8 to 12 weeks gestation by ultrasound.
Measuring Fundal Height
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.
• The pelvis can be assesses vaginally to determine whether its size is
adequate
• for a vaginal birth. This is performed by physicians of by advanced practice
• nurses. Pp. 210, Figure 10-5 & Fig. 10-6
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
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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Uterine contractions may be assessed by palpation or continuous electronic
monitoring.
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The nurse assesses contractions for frequency, duration, and intensity by
placing one hand on the uterine fundus. The hand is kept relatively still
because excessive movement may stimulate contractions or cause
discomfort.
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The frequency of the contractions are determined by noting the time from
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beginning of one contraction to the beginning of the next. To determine the
contraction duration, the nurse notes the time when tensing of the fundus is
first felt (beginning of contraction) and again as relaxation occurs (end of
contraction). Intensity can be evaluated by estimating the indentability of
the
fundus. The nurse should assess at least three successive contractions to
provide enough data to determine the contraction pattern.
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Electronic Monitoring of Contractions
Electronic monitoring provides continuous data. May be done externally
with
a device that is placed against the maternal abdomen, or internally, with an
intrauterine pressure catheter (IUPC). The external monitor is called a
toco and is positioned against the fundus of the uterus and held in place
with
an elastic belt. The toco is receptive to pressure so when the uterus
contracts,
the fundus tightens and the change in pressure against the toco is amplified
and transmitted to the electronic fetal monitor. External monitoring does not
accurately record the intensity of the uterine contraction, and it is difficult to
obtain an accurate fetal heart rate in some women.
Internal monitoring provides the same data along with accurate
measurement
of uterine contraction intensity. After membranes have ruptured, the IUPC is
inserted into the uterine cavity and connects it by a cable to the electronic
fetal monitor.
Intensity
Cervical Assessment pg 385
• Nurse will look for:
– Dilatation
0 –10 cm
– Effacement
0 – 100 %
– Station
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These are evaluated directly by vaginal examination.
Fig. 18-3, Clinical Skill
Fig. 18-4, Clinical Skill
Caused by process of labor or by Phys?
Amniotic must be clear
Mother must 1st empty bladder
Leopold’s Maneuver pg413 and pg 415
• Leopold’s maneuvers are a systematic way to evaluate the maternal
abdomen.
• Before performing Leopold’s maneuvers, have the woman (1) empty her
• bladder and(2) lie on her back with her feet on the bed and her knees
bent.
• Perform the procedure between contractions.
• First manuever – facing the woman, palpate the upper abdomen with
both
• hands, Note the shape, consistency, and mobility of the palpated part.
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Second manuever – After determining if the head or buttocks occupies
the fundus, try to determine the location of the fetal back. Still facing the
woman, palpate the abdomen with gentle but deep pressure, using the
palms. Hold the right hand steady while the left hand explores the right
side of the uterus. Then repeat the manuever, holding the left hand steady
while exploring the left side of the woman’s abdomen with your right
hand.
Leopold’s Manuever
• Fig. 18-5, pp. 414
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Third manuever – Determine what fetal part is lying just above the pelvic
outlet. To do this, gently grasp the abdomen with the thumb and fingers
just above the symphysis pubis. Note whether the presenting part feels l
ike the fetal head or buttocks and whether it is engaged.
• Fourth Manuever– Facing the woman’s feet, place both hands on the
lower
• abdomen and move the hands gently down the sides of the uterus toward
• the pubis. Attempt to locate the cephalic prominence or brow.
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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The nurse may perform Leopold’s maneuvers prior to trying to locate the FHR.
This will also aid in determining multiple fetuses, fetal lie, and fetal presentation.
Electronic Monitoring of FHR
• External
– Ultrasound
• Internal
– Fetal Scalp Electrode
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Indications for electronic monitoring: pp. 415
If one or more of the following factors are present, the fetal heart rate and
contractions are monitored by EFM
Previous history of a stillbirth at 38 weeks or more weeks’ gestation.
Presence of a complication of pregnancy (e.g. preeclampsia, placenta
previa, abruptio placentae, multiple gestation, prolonged or premature
rupture of membranes).
3. Induction of labor
4. Preterm labor
5. Decreased fetal movement
6. Nonreassuring fetal status
7. Meconium staining of amniotic fluid
8. Trial of labor following a previous cesarean birth
9. Maternal fever
10. Placental problems
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Internal monitoring requires an internal spiral electrode which is placed on the
fetal occiput. The amniotic membranes must be ruptured, the cervix must be
dilated at least 2 cm, the presenting part must be down against the cervix and
the presenting part must be known. In case of a breech presentation, the
electrode can be placed on the buttock.
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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The baseline rate refers to the average FHR rounded to increments of 5 bpm observed during a 10
minute period of monitoring. The duration should be at least 2 minutes.
Marked tachycardia - 180 or >
Variability Fig 18-?
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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
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Variability is a change in FHR over a few seconds to a few minutes.
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Baseline variability is a measure of the interplay between the
sympathetic and parasympathetic nervous systems. Baseline variability
is the fluctuations in the FHR of two cycles per minute or greater.
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)
*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
• Variability is a change in FHR over a few
seconds to a few minutes.
• Baseline variability is a measure of the
interplay between the
• sympathetic and parasympathetic nervous
systems. Baseline variability
• is the fluctuations in the FHR of two cycles
per minute or greater.
Early Decelerations p424
It’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
Late Decelerations
a 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
Variable Decelerations
Intervention 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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Variable declerations occur if the umbilical cord becomes compressed,
pp. 423)1. reducing blood flow between the placenta and fetus.
The resulting:
1.increase in peripheral resistance in the fetal circulation
causes fetal:
1.hypertension.
The fetal hypertension stimulates:
1. the baroreceptors in the aortic arch and carotid sinuses,
2. which slow the FHR.
Nursing Interventions
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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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Tocolytics is the use of medications in an attempt to stop labor.
[Drugs currently used include:]
*Magnesium sulfate
*Prostaglandin
*Calcium channel blockers
*Brethine
These drugs may suppress uterine contractions but may cause
maternal side effects such as maternal pulmonary edema.
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
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Fetal Scalp Stimulation Test – the examiner applies pressure to the fetal scalp
while doing a vaginal examination. The fetus who is not in any stress responds
with an acceleration of the FHR.
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Umbilical Cord Blood Sampling – In cases where significant abnormal FHR
patterns have been noted, meconium-stained amniotic fluid is present, or
the infant is depressed at birth, umbilical cord blood may be analyzed
immediately following birth to determine if acidosis is present. It is
recommended performing cord blood analysis incases where the Apgar score
is below 7 at 5 minutes of age. (Normal Apgar score is 7 to 10).
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Normal pH – Should be above 7.25. Lower levels indicate acidosis and hypoxia.
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Fetal Oxygen Saturation Monitoring – An intrauterine device is placed
adjacent to the fetal cheek or temple maintaining constant contact with
the fetal skin. Using pulse oximetry, the monitor displays fetal oxygenation
saturation as a percentage of oxygen within the fetal blood. Levels of 40%
to 70% are considered reassuring. Levels less than 30% indicate hypoxia
and require immediate birth.