Intrapartal Nursing
Assessment
Linda L. Franco RN MSN NE-BC
Green = Need to Know
Red = Important to know
Blue = History
Maternal Assessment
• History
– List p 399
• Intrapartal High-Risk Screening
– Table 18 -1
• Intrapartal Physical and Psychosociocultural
Assessment
– Assessment Guide p 403 -408
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)
• Nagele’s Rule – the first day of the last menstrual
period, subtract 3 months, and add 7 days.
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.
• The pelvis can be assess vaginally to see if it’s
adequate to have vaginal birth. Don’t perform
on a woman with bleeding!
Intrapartal Nursing Assessment
• Maternal Assessment
– Evaluating labor progress
– Electronic monitoring of contractions
– Cervical assessment
• Fetal Assessment
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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
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. Doesn’t accurately
recorded the intensity
– Internal
• IUPC (intrauterine something catheter) membrane must be ruptured and
dilated to at least 2 to use this guy
Intensity
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)
Leopold’s Manuever
Leopold’s Manuever
Auscultation of Fetal Heart Rate
• FHR – heard most clearly at fetal back, put
toco (sp? External device thing) on it’s back
– Cephalic
• Lower quadrants
– Breech
• Upper quadrants
– Transverse Lie
• Umbilicus
Electronic Monitoring of FHR
• External
– Ultrasound
• Internal
– Fetal Scalp Electrode
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
Variability
• Short-term – beat to beat
• Long-term – rhythmic fluctuations of the entire strip
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Absent – undetectable
Minimal – amplitude < 5 bpm
Moderate – amplitude 6 – 25 bpm
Marked – amplitude > 25
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
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 we’re good)
– Early
– Late
– Variable
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
Late Decelerations
• Onset occurs after the onset of the
contraction
• Uniform in shape
• Caused from uteroplacental insufficiency
– For some reason the uterus isn’t getting the
oxygen it needs
• Nonreassuring but does not necessarily
require immediate delivery
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 baby’s HR to go
down
• Requires further assessment
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
Fetal Blood Sampling
• Fetal Scalp Stimulation Test
• Umbilical Cord Blood Sampling
• Normal pH 7.20 – 7.25
• Fetal Oxygen Saturation Monitoring