intrapartal nursing assessment. maternal assessment 1. history general health medications allergies...
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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