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 60-90 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