NAME OF STUDENT: BALACUIT, MARY REGINE BSN-2

Procedure 2.1: Assessment of Uterine Contractions (First Stage)

Purpose: To distinguish from true labor from false labor so that medical
interventions can be started and given.
PROCEDURE RATIONALE
1. Explain procedure to the woman. To gain consent, cooperation and promote
sense of comfortability.
2. Ensure woman’s bladder is empty. For comfortability and accurate
assessment because, the distension of
uterine contraction can delay the stages of
labor and the uterus could not contract
well.
3. Assemble equipment. For easy access and time efficiency while
conducting the examination ensuring that
we can render quality service care to both
mother and child.
4. Put the mother in dorsal To easily access and assess her abdomen
recumbent position & screen the the patient should be lying on the bed
mother’s bed. comfortably and check the bed for safety
and comfortability.
5. Assist the woman to relax by To decrease anxiety and improve proper
encouraging her to breathe oxygenation.
naturally & to take deep breaths
during contractions.
6. Place fingertips of one hand on To determine the contractions accurately.
uterus, keep fingertips relatively
still rather than moving them over
uterus.
7. Note time when each contraction To determine if the woman is ready for
begins & ends to determine: labor and to distinguish true labor from
 Frequency by calculation false labor.
average time that elapses from
beginning of one contraction until
beginning of next one
 Duration by noting average time
in seconds from beginning to end
of each contraction.
 Interval by noting average time
between end of one contraction &
beginning of the next one.
 8. Auscultate fetal heart rate after To determine presence and status of the
each contraction reading. fetal heart rate and detect underlying
problems
9. Monitor the vital signs for the To improve and maintain patient’s safety
woman. and as a baseline data for future
comparison.
10. Observe the woman for any To be aware and be alert for immediate
abnormal uterine contractions and medical interventions to be given in case
fetal heart rate. emergency persists because uterine
activity during pregnancy is linked to a
graded response in fetal heart rate and
may pose a physiological challenge to the
fetal cardiovascular system's growth and
adaptation.
11. Wash hands and document the To prevent the spread of microorganisms
finding. and contamination as well as to serve as
the baseline data

Procedure 2.2: Auscultating Fetal Heart Rate during Labor

Purpose: To know the fetal heart rate condition, to aid in the detection of
abnormal heart rate patterns during labor and steps can be done to treat the
underlying condition if specific alterations are discovered. Fetal heart rate
monitoring can also help prevent unnecessary medical interventions.
PROCEDURE RATIONALE
12. Explain procedure to the woman. To gain consent, cooperation and promote
sense of comfortability.
13. Ensure woman’s bladder is empty. The patient should have an empty bladder
to avoid erroneous measurements and
pain.
14. Assemble equipments. For easy access and time efficiency while
conducting the examination ensuring that
we can render quality service care to both
mother and child.
15. Place the ultrasonic gel on the To aid in maintaining contact with the
diaphragm of the Doppler. maternal abdomen and enhances
conduction of sound
16. Place the Doppler diaphragm on This position will aid us to hear and know
the woman’s abdomen halfway the condition of fetal heart rate.
 between the umbilicus and
symphysis and in the midline.
17. Check the woman’s pulse against
the fetal sounds you hear. If the
rates are the same, reposition the
Doppler.
18. If the rates are not similar, count
the FHR for 1 full minute.
19. Auscultate the FHR between,
during and for 30 seconds
following a uterine contraction.
20. Document the fetal heart rate
count.
Procedure 2.3 :Vaginal Examination During Labor
Purpose: To know the fetal descent, fetal pattern, duration and how dilated the
cervix is.
PROCEDURE
1. . Explain procedure to the woman &
maintain privacy.
2. Ensure woman's bladder is empty.
3. Assemble equipments
4. Assist woman into supine position
on exam table with lower
extremities flexed and rotated
outward, her heels should be
supported in stirrup which are level
with the table about 1 - 2 Ft in front
of her buttocks [Lithotomy position].
To know whether the fetal sounds are
accurately from the fetus because if the
rate is the same, you’re probably hearing
the mother’s heart sounds.
To detect deviation from normal for further
interventions needed. The Normal fetal
heart rate is 110 to 160 beats per minute
During uterine contractions, the head of the
fetus is pressed. When the pressure in the
uterus is increased, this might cause the
fetal heart rate to slow down.
For baseline data, medical record and
future comparison.
RATIONALE
To establish rapport, preserve modesty,
dignity and comfortability.
The patient should have an empty bladder
to avoid erroneous measurements, pain
and discomfort.
For easy access and time efficiency while
conducting the examination ensuring that
we can render quality service care to both
mother and child.
This position is best for vaginal
examination because of its easy access in
assessment result. Moreover, assistance
should be provided for ensuring the safety
of the mother and child.
5. Assist the woman to relax by
encouraging her to breathe
naturally.
6. Expose the perineal area for
examination.
7. Prepare the area with antiseptic
solution.
8. Put on gloves, from standing
position using thumb & fore finger of
non-dominant hand to spread the
labia.
9. Insert the well lubricated index &
middle fingers of dominant hand
into the vagina until they touch the
cervix, using downward & upward
direction and keep thumb of
dominant hand upward and
supported on vulva.
10. Note presentation, position of fetus,
cervical dilatation & effacement,
station of fetal head, status of
membranes.
11. Provide care with antiseptic solution
& put on sterile pad after care.
12. Remove the equipment & gloves.
13. Wash hands and document the
finding.
To decrease anxiety and improve proper
oxygenation.
To check for changes constituting the
labor.
To ensure sterility and hygiene.
To ensure sterility and hygiene as well
ensuring a clear view for inspection.
To feel the fetal descent and be able to
measure it.
To have a record for assessment and
interventions needed.
To ease discomfort while ensuring sterility
and hygiene.
To prevent contaminations.
Maintain proper hygiene and to have a
baseline data for medical record and
references purposes.