Intrapartal Nursing Assessment

1. - Tie everything together Intrapartal Nursing Assessment Sue Nesbitt, RN, MSN

2. 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.

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

4. + • 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.

5. 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.

6. + • 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 • 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 • 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. • Fetal Heart Rate –Fetal heartbeat can be detected, on average, • at 8 to 12 weeks gestation by ultrasound.

7. Measuring Fundal Height

8. 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

9. 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

10. 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)

11. Uterine contractions may be assessed by palpation or continuous electronic • monitoring. • 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. • The frequency of the contractions are determined by noting the time from the • 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.

12. 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.

13. Intensity

14. Cervical Assessment pg 385 • Nurse will look for: • Dilatation 0 –10 cm • Effacement 0 – 100 % • Station -3 to + 3 • 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

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

16. 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. • 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.

17. Leopold’s Manuever

18. Fig. 18-5, pp. 414 • 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.

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

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

21. 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 • 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.

22. 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 • 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 >

23. 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 • 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.

24. 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)

25. *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

26. 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.

27. 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

28. 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

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

30. 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) • 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.

31. 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

32. 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. • 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). • Normal pH – Should be above 7.25. Lower levels indicate acidosis and hypoxia. • 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.