WEEK 4 EDAPT NR 327 NOTES
INTRAPARTUM PERIOD
The assessment and evaluation of contractions are necessary to establish baseline
data. Without adequate
... [Show More] frequency and duration of contractions, labor may fail to
progress.
Though it is important to understand the client's pregnancy history, as this may impact
the speed and progression of labor, it is not the priority assessment. While having a
labor partner is helpful as labor progresses, it is not the priority assessment during
admission. Documenting the time of last meal is important, especially if cesarean birth is
necessary. However, this is not the priority assessment during admission.
Question: The nurse is caring for a client in labor who is receiving oxytocin.
Which assessment finding requires immediate action?
Uterine tachysystole (hyperstimulation) is defined as more than 5 contractions in 10
minutes (or contractions closer than 2 minutes in frequency). Tachysystole can result in
decreased fetal oxygenation and requires immediate action.
Question: What are indications for labor induction?
Indications for labor induction may include:
Maternal factors:
premature or prolonged rupture of membranes
preeclampsia/eclampsia
history of fetal stillbirth or demise
diabetes mellitus
history of precipitous (less than 3 hours) labor
chorioamnionitis
oligohydramnios
post-term gestation
Fetal factors:
intrauterine growth restriction (IUGR)
non-reassuring fetal heart rate and pattern
fetal complications, such as erythroblastosis fetalis and hydrops
significant congenital anomalies
Maternal request for convenience is not an indication for induction of labor. Labor
induction is contraindicated with placenta previa. A cesarean birth is necessary.
INTRAPARTUM TERMINOLOGY:
SVE - Sterile vaginal examination is an assessment performed by RN to determine
cervical dilation, effacement, and fetal station.
PROM - Premature rupture of membranes is the spontaneous rupture of the membranes before
the onset of labor at any gestational age.
Effacement - Effacement is the shortening and thinning of the cervix during the first
stage of labor - the drawing up of the internal os and the cervical canal into the uterine
side walls. Measured as a percentage: 0% is approximately 1 cm thick; 100% is paper
thin.
Engagement - The ischial spines are the narrowest diameter through which the fetus
must pass; designated as 0 station. When the presenting part reaches 0 station, the
fetus is said to be engaged in the pelvis.
NST - NST stands for nonstress test. Reactive (normal) NST = In 20 minutes, at least 2
accelerations in fetal heart rate >15 bpm above baseline for >15 seconds
AROM: Augmented (also called artificial) rupture of membranes
Cephalic Presentation: Fetus positioned head down; most common fetal presentation
Dilation: Progressive opening of cervix caused by uterine contractions; 0–10 cm
Effacement: Shortening and thinning of the cervix within stage one of labor
EFM: Electronic fetal monitoring
Engagement: Fetal presenting part reaches true pelvis
FHR: Fetal heart rate
Fundus: Upper aspect of the uterus
Intrapartum: Onset of labor to birth
Lightening: Descent of fetal presenting part into the pelvic cavity, often 38 weeks
gestation (or 2 weeks before labor onset in primiparas)
NST: Nonstress test; fetal assessment for well-being, (2) accelerations documented with
15 bpm above baseline × 15 seconds in length minimum = (+) NST
PROM: Premature rupture of membranes; no contraction or no dilation noted, but
SROM occurred
SROM: Spontaneous rupture of membranes
Station: Relation of the presenting part to the ischial spines of maternal pelvis
SVE: Assessment performed by RN to determine cervical dilation, station, and
effacement.
Childbirth and associated intimate medical interventions may trigger feelings of anxiety
and fear in women who are survivors of sexual abuse. Nurses should provide emotional
support, helping the client to associate uncomfortable experiences with the birth of a
child, instead of past abuse. Providing information and privacy while allowing client
control may reduce anxiety and fear.
Laboring women who are survivors of sexual abuse need to be kept continually
informed of labor progress in order to avoid stress and anxiety.
Childbirth preparation classes:
There are many different types of childbirth preparation techniques taught to clients.
Though all methods provide instruction on pain management techniques, each has
unique aspects. Some of the common classes offered are:
Dick-Read Childbirth Education focuses on alleviating the fear of childbirth
through education and the pain through relaxation and breathing techniques.
Bradley Childbirth Education teaches abdominal breathing to increase relaxation
and emphasizes the avoidance of medications and interventions.
Lamaze Childbirth Education teaches concentration and relaxation to decrease
contraction pain.
FETAL HEART RATE AND PATTERN:
The primary and most reliable way to assess the status of a fetus is to monitor the fetal
heart rate and pattern. This can be done using continuous electronic fetal monitoring
(EFM) or intermittently using an electronic doppler. Assessing the fetal heart rate and
pattern is a priority during admission. The normal range for fetal heart rate is between
110 and 160 bpm. The pattern may include accelerations and early decelerations.
However, variable and late decelerations are ominous and should be evaluated further.
The frequency of fetal monitoring during labor is determined by the client’s level of risk.
During active labor, the nurse should plan to monitor at least every 30 minutes.
When assessing the fetal heart rate and pattern, consider these questions:
What is the baseline fetal heart rate (FHR)?
What is the FHR variability?
Are accelerations in the FHR present?
Does the FHR meet reactive non-stress test criteria?
Are any decelerations present? If yes, what type of deceleration is occurring? Are
interventions needed?
NOTE:
Nurses who care for women during childbirth are legally responsible for correctly
interpreting the fetal heart rate pattern, implementing appropriate nursing actions based
on that pattern, and documenting the outcome of those actions.
Contraction pattern:
External electronic fetal monitoring (EFM) does not measure uterine tone unless an
internal monitor is in place, so the nurse palpates the abdomen to assess uterine
contraction strength manually. The palpable tone (strength) of contractions is described
as mild, moderate, or strong.
When palpating the fundus, consider these questions:
What is the intensity (strength) of the contraction?
What is the intensity of the resting period after the contraction ends? The tone of
the resting period should feel soft, like the upper lip.
Frequency, duration, onset, and regularity of contractions are assessed as part of the
intrapartum admission nursing assessment. When assessing contractions, the nurse
should consider these questions:
What is the frequency of the contractions? Frequency is the time between the
beginning of one contraction and the beginning of the next contraction.
What is the duration of the contractions? Duration is the time from the beginning
of the contraction to the end of the same contraction.
While evaluating contractions, the nurse should ask the client:
What is the pain level of the contractions?
What is a tolerable level of pain for the client?
Vital signs:
Vital signs should be monitored frequently during labor. The nurse should plan on hourly
assessments for blood pressure, pulse, and respirations unless complications or
analgesia warrant increased frequency. Temperature will be monitored every 4 hours
until the membranes are ruptured, then hourly. Abnormal parameters compared to the
client's baseline should be reported to the healthcare provider and may change the
frequency of evaluations.
Pain level should be monitored continuously as increased pain can elevate both blood
pressure and pulse rate.
AMNIOTIC MEMRANES:
Amniotic membranes are assessed before the initial cervical examination to accurately
determine if amniotic fluid is leaking. Yellow nitrazine paper may be used to detect
amniotic fluid, which has a basic pH.
A blue color change is indicative of the presence of amniotic fluid.
No color change indicates lack of amniotic fluid (so no membrane rupture).
Ask the client these questions:
Has your water broken?
What time did it break?
What did the fluid look like?
About how much fluid did you lose? Was it a big gush or a small trickle?
If the amniotic membranes are ruptured, assess, and document the time of rupture,
amount, color, and odor of fluid (think of TACO).
T = Time that the amniotic membrane ruptured
A = Amount of amniotic fluid that came out
C = Color of the leaked amniotic fluid
clear—normal
greenish meconium
yellow/cloudy—potential infection, called chorioamnionitis
O = Odor of the leaked amniotic fluid
odorless—normal
foul/strong odor—potential infection
CERVICAL EXAMINATION AND DILATATION:
Cervical dilation is a key nursing assessment for determining if the woman is in true
labor.
If the facility’s policy permits, a sterile vaginal exam (SVE) is often performed by the
nurse as part of the intrapartum admission and ongoing assessment, which is to
determine:
cervical dilation (the widening of the cervical opening)
cervical effacement (shortening and thinning of the cervix)
fetal station (the relationship of the presenting part to the ischial spines in the
maternal pelvis)
A baseline sterile cervical exam, in conjunction with other assessment f [Show Less]