INTRAPARTAL NURSING ASSESSMENT

Maternal Assessment 1. History General health Medications Allergies Obstetrical Labor Birth plan

Risk Assessment Bleeding Rom Hospitalizations Preterm labor PIH Diabetes Abnormal presentation

Physical Assessment Admission Assessment Labor status Contraction pattern Cervical dilation and effacement Fetal descent Membranes Fetal status laboratory

Fetal Assessment Assess fetal position Inspection Palpation: Leopold’s maneuvers Vaginal exam and ultrasound

Fetal Heart Rate Tools Fetoscope Doppler EFM External or internal Baseline rate: 120 to 160 Abnormal Fetal Heart Rates Tachycardia: sustained rate of 161 or above Marked: 180 or above Causes Early Hypoxia Maternal Fever Dehydration Drugs Amniotitis Hyperthyroidism Fetal anemia

Fetal Bradycardia Rate Less than 120 during a 10 minute period or longer Causes: Late or severe fetal hypoxia Maternal Hypotension Prolonged umbilical cord compression Fetal arrhythmia

Variability: Short Term Long – Term Absent decreased Average Increased Marked

Decelerations Early Late Variable

Non-Reassuring Patterns Severe variable decelerations or FHR drops below 70 for longer than 30 to 45 seconds Late decelerations of any magnitude Absence of variability Prolonged decels that lasts seconds or more Severe marked bradycardia of 70 or less

Nursing management of Decelerations Turn mom to left side Administer O2 by face mask at 7-10 L Discontinue oxytocin Increase IV fluids Assess labor progress by SVE Notify physician Monitor VS and stay with pt.

Scalp Stimulation Fetal scalp blood sampling