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

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 Intrapartal Physical and Psychosociocultural Assessment – Assessment Guide p

+ 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.

+ 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.

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)

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.

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 -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

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

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.

Leopold’s Manuever

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.

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.

Electronic Monitoring of FHR External – Ultrasound Internal – Fetal Scalp Electrode

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 1.Previous history of a stillbirth at 38 weeks or more weeks’ gestation. 2.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.

Fetal Heart Rates pg 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 or >

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.

Variability con. Pg 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 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 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.

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

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 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.