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lon23944_ch18.qxd 2/14/06 4:45 PM Page 420 CHAPTER Intrapartal 18 Nursing Assessment It was strange. After months of waiting for my baby s birth, labor took me by surprise. I wasn t quite ready to move
lon23944_ch18.qxd 2/14/06 4:45 PM Page 420 CHAPTER Intrapartal 18 Nursing Assessment It was strange. After months of waiting for my baby s birth, labor took me by surprise. I wasn t quite ready to move from being pregnant to being a mother. Not that I had any choice! Tammy, 23 LEARNING OBJECTIVES Discuss high-risk screening and intrapartal assessment of maternal physical and psychosociocultural factors. Summarize methods used to evaluate the progress of labor. Describe auscultation of fetal heart rate. Delineate the procedure for performing Leopold s maneuvers and the information that can be obtained. Differentiate between baseline and periodic changes in fetal heart rate monitoring and describe the appearance and significance of each. Outline steps to be performed in the systematic evaluation of fetal heart rate tracings. Identify nonreassuring fetal heart rate patterns and appropriate nursing responses. Discuss nursing care of the family undergoing electronic fetal monitoring. Delineate the indications for fetal blood sampling and identify related ph values. Describe how fetal oxygen saturation (FSpO 2 ) monitoring uses pulse oximetry to monitor fetal oxygenation within the fetal blood to determine if hypoxia is occurring. M EDIAL INK CD-ROM Skill 3 1: Performing an Intrapartal Vaginal Examination Skill 3 3: Performing Leopold s Maneuvers Skill 3 4: Auscultation of Fetal Heart Rate Skill 3 5: External Electronic Fetal Monitoring Skill 3 6: Electronic Fetal Monitoring Audio Glossary NCLEX-RN Review Companion Website Thinking Critically NCLEX-RN Review MediaLink Applications: Case Study: Maternal Assessment during Labor Care Plan Activity: Client with Decelerations 420 lon23944_ch18.qxd 2/14/06 4:45 PM Page 421 The physiologic events during labor call for many adaptations by the mother and the fetus. Thus, frequent and accurate assessments are crucial. The woman s partner or chosen support person is also an integral part of the childbirth experience. In nursing practice the traditional assessment techniques of observation, palpation, and auscultation are augmented by the judicious use of technology such as ultrasound and electronic monitoring. These tools may provide more detailed information for assessment. However, the technology only provides data; it is the nurse who monitors the mother and her baby. MATERNAL ASSESSMENT HISTORY Obtain a brief oral history when the woman is admitted to the birthing area. Each agency has its own admission forms, but they usually include the following information: Woman s name and age Last menstrual period (LMP) and estimated date of birth (EDB) Attending physician or certified nurse-midwife (CNM) Personal data: blood type; Rh factor; results of serology testing; prepregnant and present weight; allergies to medications, foods, or other substances; prescribed and over-the-counter medications taken during pregnancy; and history of drug and alcohol use and smoking during the pregnancy History of previous illness, such as tuberculosis, heart disease, diabetes, and so forth Problems in the prenatal period, such as elevated blood pressure, bleeding problems, recurrent urinary tract infections, other infections Pregnancy data: gravida, para, abortions, and perinatal deaths The method chosen for infant feeding Type of prenatal education classes (childbirth education classes) Woman s preferences about labor and birth, such as no episiotomy, no analgesics or anesthetics, or the presence of the father or others at the birth Pediatrician or family practice physician Additional data: history of special tests such as nonstress test (NST), biophysical profile (BPP), or ultrasound; history of any preterm labor; onset of labor; amniotic fluid membrane status; and brief description of previous labor and birth Onset of labor Status of amniotic membranes (Are they intact or ruptured? If ruptured, time of rupture, color of fluid, and odor.) KEY TERMS Accelerations, 439 Baseline rate, 437 Decelerations, 439 Electronic fetal monitoring, 435 Fetal arterial oxygen saturation, 444 Fetal blood sampling, 443 Fetal bradycardia, 438 Fetal tachycardia, 437 Intrauterine pressure catheter, 430 Late deceleration, 440 Leopold s maneuvers, 433 Long-term variability, 438 Short-term variability, 438 Variable decelerations, 440 The psychosocial history is a critical component of intrapartal nursing assessment. Because of the prevalence of domestic violence in society, the nurse needs to consider the possibility that the woman may have experienced abuse at some time in her life. The following screening questions should be asked universally when the woman is alone so that she can answer freely (American College of Obstetricians and Gynecologists [ACOG], 1999): 1. Has anyone close to you ever threatened to harm you? 2. Have you ever been hit, slapped, kicked, choked, or otherwise physically hurt by someone? If yes, by whom? Total number of times? 421 lon23944_ch18.qxd 2/14/06 4:45 PM Page CHAPTER Has anyone, including your partner, ever forced you to have sex? 4. Are you afraid of your partner or anyone you mentioned? NURSING PRACTICE Many nurses have difficulty asking questions about domestic violence, sexual abuse, and drug or alcohol use during pregnancy. However, this information is necessary to provide the best nursing care possible. To create a relationship of trust in which the client feels safe answering uncomfortable questions, the following tips may be helpful: Explore your own beliefs and values. Use open-ended questions. Be receptive to the answers. Be accepting of others life experiences. INTRAPARTAL HIGH-RISK SCREENING Screening for intrapartal high-risk factors is an integral part of assessing the normal laboring woman. As the history is obtained, note the presence of any factors that may be associated with a high-risk condition. For example, the woman who reports a physical symptom such as intermittent bleeding needs further assessment to rule out abruptio placentae or placenta previa before the admission process continues. It is also important to recognize the implications of a highrisk condition for the laboring woman and her fetus. For example, if there is an abnormal fetal presentation, labor may be prolonged, prolapse of the umbilical cord is more likely, and the possibility of a cesarean birth is increased. Although physical conditions are major factors that increase risk in the intrapartal period, sociocultural variables THINKING CRITICALLY You are the birthing center nurse and you have reason to suspect that Lynn Ling, who has just been admitted in labor, may be in an abusive relationship. How could you set up an interview so that the partner would leave the room (and take any accompanying children) without feeling that you are possibly increasing the risk to the woman? What communication techniques would you use to encourage Lynn to reveal if her partner is abusive? such as poverty, nutrition, the amount of prenatal care, cultural beliefs about pregnancy, and communication patterns may also precipitate a high-risk situation. In addition, women who suffer from post-traumatic stress disorder may be at increased risk for some pregnancy complications (Seng et al.,2001).other risk factors include smoking,drug use,and consumption of alcohol during pregnancy (Davidson, 2002). Begin gathering data about sociocultural factors as the woman enters the birthing area. Observe the communication pattern between the woman and her support person or people and their responses to admission questions and initial teaching. If the woman and those supporting her do not speak English and translators are not available among the birthing unit staff, the course of labor and the ability of caregivers to interact and provide support and education are affected. The couple must receive information in their primary language to make informed decisions. Communication may also be affected by cultural practices such as beliefs about when to speak, who should ask questions, or whether it is acceptable to let others know about discomfort. Table 18 1 provides a partial list of intrapartal risk factors to keep in mind during the intrapartal assessment. TABLE 18 1 Intrapartal High-Risk Factors Factor Maternal Implications Fetal-Neonatal Implications Abnormal presentation Incidence of cesarean birth Incidence of placenta previa Incidence of prolonged labor Prematurity Risk of congenital abnormality Neonatal physical trauma Risk of intrauterine growth restriction (IUGR) Multiple gestation Uterine distention risk of postpartum Low birth weight hemorrhage Prematurity Risk of cesarean birth Risk of congenital anomalies Risk of preterm labor Feto-fetal transfusion Hydramnios Discomfort Risk of esophageal or other high-alimentary-tract Dyspnea atresias Risk of preterm labor Risk of CNS anomalies (myelocele) Edema of lower extremities lon23944_ch18.qxd 2/14/06 4:45 PM Page 423 Intrapartal Nursing Assessment 423 TABLE 18 1 Intrapartal High-Risk Factors continued Factor Maternal Implications Fetal-Neonatal Implications Oligohydramnios Maternal fear of dry birth Incidence of congenital anomalies Incidence of renal lesions Risk of IUGR Risk of fetal acidosis Risk of cord compression Postmaturity Meconium staining of amniotic fluid Psychologic stress due to fear for baby Risk of fetal asphyxia Risk of meconium aspiration Risk of pneumonia due to aspiration of meconium Premature rupture of membranes Risk of infection (chorioamnionitis) Perinatal morbidity Risk of preterm labor Prematurity Anxiety Birth weight Fear for the baby Risk of respiratory distress syndrome Prolonged hospitalization Prolonged hospitalization Incidence of tocolytic therapy Induction of labor Risk of hypercontractility of uterus Prematurity if gestational age not assessed correctly Risk of uterine rupture Length of labor if cervix not ready Hypoxia if hyperstimulation occurs Anxiety Abruptio placentae/placenta previa Hemorrhage Fetal hypoxia/acidosis Uterine atony Fetal exsanguination Incidence of cesarean birth Perinatal mortality Failure to progress in labor Maternal exhaustion Fetal hypoxia/acidosis Incidence of augmentation of labor Intracranial birth injury Incidence of cesarean birth Precipitous labor ( 3 hours) Perineal, vaginal, cervical lacerations Tentorial tears Risk of postpartum hemorrhage Prolapse of umbilical cord Fear for baby Acute fetal hypoxia/acidosis Cesarean birth Fetal heart aberrations Fear for baby Tachycardia, chronic asphyxic insult, bradycardia, acute Risk of cesarean birth, forceps, vacuum asphyxic insult Continuous electronic monitoring and intervention Chronic hypoxia in labor Congenital heart block Uterine rupture Hemorrhage Fetal anoxia Cesarean birth for hysterectomy Fetal hemorrhage Risk of death Neonatal morbidity and mortality Postdates ( 42 weeks) Anxiety Postmaturity syndrome Incidence of induction of labor Risk of fetal-neonatal mortality and morbidity Incidence of cesarean birth Risk of antepartum fetal death Use of technology to monitor fetus Incidence or risk of large baby Risk of shoulder dystocia Diabetes Risk of hydramnios Risk of malpresentation Risk of hypoglycemia or hyperglycemia Risk of macrosomia Risk of preeclampsia-eclampsia Risk of IUGR Risk of respiratory distress syndrome Risk of congenital anomalies Preeclampsia-eclampsia Risk of seizures Risk of small-for-gestational-age baby Risk of stroke Risk of preterm birth Risk of HELLP Risk of mortality AIDS/STI Risk of additional infections Risk of transplacental transmission lon23944_ch18.qxd 2/14/06 4:45 PM Page CHAPTER 18 INTRAPARTAL PHYSICAL AND PSYCHOSOCIOCULTURAL ASSESSMENT Aphysical examination is part of the admission procedure and part of the ongoing care of the woman. Although the intrapartal physical assessment is not as complete and thorough as the initial prenatal physical examination (see Chapter 10 ), it does involve assessment of some body systems and the actual labor process. See Assessment Guide: Intrapartal First Stage of Labor for a framework to use when examining the laboring woman. The physical assessment portion includes assessments performed immediately on admission as well as ongoing assessments. When labor is progressing very quickly, there may not be time for a complete nursing assessment. In that case the critical physical assessments include maternal vital signs, labor status, fetal status, and laboratory findings. The cultural assessment portion provides a starting point for this increasingly important aspect of assessment. Individualized nursing care can best be planned and implemented when the values and beliefs of the laboring woman are known and honored. It is sometimes challenging to achieve a balance between cultural awareness and the risk of stereotyping because cultural responses are influenced by so many factors. Nurses are most effective when they combine an awareness of the major cultural values and beliefs of a specific group with the recognition that individual differences have an impact. Developing Cultural Competence provides examples of selected beliefs of some Native American women. DEVELOPING CULTURAL COMPETENCE The following list provides a few examples of the beliefs and taboos of some Native American women related to childbirth (Cesario, 2001): If a pregnant woman eats the feet of animals, her infant will be born feet first. If a pregnant woman eats an animal s tail, her infant will get stuck in the birth canal. Weaving or tying knots during pregnancy will cause umbilical cord complications. If the woman naps during labor it may cause a change in the desired sex of her infant. A lengthy labor may result if a woman is exposed to cold during pregnancy because cold causes the woman s bag of waters to freeze, thereby holding the infant back. When the infant s cord is being cut following birth, the mother should bite on a white pebble. This ensures that the infant s teeth will be white and strong. The final section of the assessment guide addresses psychosocial factors. The laboring woman s psychosocial status is an important part of the total assessment. The woman has previous ideas, knowledge, and fears about childbearing. By assessing her psychosocial status, the nurse can meet the woman s needs for information and support. While performing the intrapartal assessment, it is crucial to follow the Centers for Disease Control and Prevention (CDC) guidelines to prevent exposure to body substances. Provide information about the precautions in a factual manner. METHODS OF EVALUATING LABOR PROGRESS The nurse assesses the woman s contractions and cervical dilatation and effacement to evaluate labor progress. Contraction Assessment Uterine contractions may be assessed by palpation or continuous electronic monitoring. Palpation. Assess contractions for frequency, duration, and intensity by placing one hand on the uterine fundus. It is important to keep the hand relatively still because excessive movement may stimulate contractions or cause discomfort. Determine the frequency of the contractions by noting the time from the beginning of one contraction to the beginning of the next. If contractions begin at 7:00, 7:04, and 7:08, for example, their frequency is every 4 minutes. To determine contraction duration, note the time when tensing of the fundus is first felt (beginning of contraction) and again as relaxation occurs (end of contraction). During the acme of the contraction, intensity can be evaluated by estimating the indentability of the fundus. Assess at least three successive contractions to provide enough data to determine the contraction pattern. See Table 18 2 for a review of characteristics in different phases of labor. NURSING PRACTICE Many experienced nurses note that mild contractions are similar in consistency to the tip of the nose, moderate contractions feel more like the chin, and with strong contractions, there is little indentability, much like the forehead. When palpating a woman s uterus during a contraction, compare the consistency to your nose, chin, and forehead to determine the intensity. This is also a good time to assess the laboring woman s perception of pain. For example, how does she describe the pain? What is her affect? Is this contraction more uncomfortable than the last one? Note and chart the woman s affect and response to the contractions. Electronic Monitoring of Contractions.. Electronic monitoring of uterine contractions provides continuous data. In many birth settings, electronic monitoring is routine for high-risk clients lon23944_ch18.qxd 2/14/06 4:45 PM Page 425 Intrapartal Nursing Assessment 425 Vital Signs ASSESSMENT GUIDE INTRAPARTAL FIRST STAGE OF LABOR PHYSICAL ASSESSMENT/ ALTERATIONS AND NURSING RESPONSES NORMAL FINDINGS POSSIBLE CAUSES* TO DATA Blood pressure (BP): 130 systolic and 85 diastolic in adult 18 years of age or older or no more than mm Hg rise in systolic pressure over baseline BP during early pregnancy Pulse: beats per minute (bpm) Respirations: 14 22/minute (or pulse rate divided by 4) Pulse oximeter (if used) 95% or greater Temperature: C ( F) Weight lb greater than prepregnant weight Lungs Normal breath sounds, clear and equal Fundus At 40 weeks gestation located just below xiphoid process Edema Slight amount of dependent edema Hydration Normal skin turgor, elastic Perineum Tissues smooth, pink color (see Prenatal Initial Physical Assessment Guide, Chapter 10) High BP (essential hypertension, preeclampsia, renal disease, apprehension or anxiety) Low BP (supine hypotension) Increased pulse rate (excitement or anxiety, cardiac disorders, early shock) Marked tachypnea (respiratory disease), hyperventilation in transition phase Hyperventilation (anxiety) 90%; hypoxia, hypotension, hemorrhage Elevated temperature (infection, dehydration, prolonged rupture of membranes, epidural regional block) Weight gain 35 lb (fluid retention, obesity, large infant, diabetes mellitus, preeclampsia), weight gain 15 lb (SGA, substance abuse, psychosocial problems). Rales, rhonchi, friction rub (infection), pulmonary edema, asthma Uterine size not compatible with estimated date of birth (SGA, large for gestational age [LGA], hydramnios, multiple pregnancy, placental/fetal anomalies, malpresentation) Pitting edema of face, hands, legs, abdomen, sacral area (preeclampsia) Poor skin turgor (dehydration) Varicose veins of vulva, herpes lesions, genital warts Evaluate history of preexisting disorders and check for presence of other signs of preeclampsia. Do not assess during contractions; implement measures to decrease anxiety and reassess. Turn woman on her side and recheck BP. Provide quiet environment. Have O 2 available. Evaluate cause, reassess to see if rate continues; report to physician. Assess between contractions; if marked tachypnea continues, assess for signs of respiratory disease. Encourage slow breaths if woman is hyperventilating. Apply O 2 ; notify physician Assess for other signs of infection or dehydration. Assess for signs of edema. Evaluate pattern from prenatal record. Reassess; refer to physician. Reevaluate history regarding pregnancy dating. Refer to physician for additional assessment. Check deep tendon reflexes for hyperactivity; check for clonus; refer to physician. Assess skin turgor; refer to physician for deviations. Exercise care while doing a perineal prep; note on client record need for follow-up in postpartal period; reassess after birth; refer to physician/cnm. * Possible causes of alterations are placed in parentheses. This column provides guidelines for further assessment and initial nursing intervention. (continued) lon23944_ch18.qxd 2/14/06 4:45 PM Page CHAPTER 18 ASSESSMENT GUIDE continued INTRAPARTAL FIRST STAGE OF LABOR PHYSICAL ASSESSMENT/ ALTERATIONS AND NURSING RESPONSES NORMAL FINDINGS POSSIBLE CAUSES* TO DATA Perineum (continued) Clear mucus; may be blood tinged with earthy or human odor Presence of small amount of bloody show that gradually increases with
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