Maternal and Fetal Assessment during Labor and Birth

What is priority after spontaneous rupture of membrane?

Assess FHR immediately because cord prolapse/compression can compromise fetus

What does clear/pale-yellow amniotic fluid indicate?

Generally normal amniotic fluid

What does green/yellow-green amniotic fluid indicate?

Meconium-stained fluid, requiring closer fetal assessment

What can cloudy or foul-smelling amniotic fluid suggest?

Possible infection

How is contraction frequency measured?

From beginning of one contraction to the beginning of the next

How is contraction duration measured?

From the beginning to end of one contraction

Assessing contraction intensity by palpating uterine fundus

Placing fingertips on fundus during contraction and comparing it to tip of nose (mild) → chin (moderate) → forehead (strong)

Leopold’s Maneuver

Determines fetal lie, presentation, position, and engagement/attitude

What is assessed with the first Leopold maneuver?

Fundus is palpated to determine whether fetal head or buttocks is present to identify presentation

What is assessed with the second Leopold maneuver?

Palpate both sides (lateral) of abdomen to identify fetal back where FHR is best heard

What is assessed with the third Leopold maneuver (Pawlik’s grip)?

Palpate just above symphysis pubis to determine presenting part entering pelvis (head, buttocks, etc.)

What is assessed with the fourth Leopold maneuver?

Palpate lower abdomen to identify fetal head for flexion/extension and if it’s engaged

What is normal baseline FHR?

110-160 BPM

How is FHR baseline determined?

Average FHR over 10-minute period, not including accelerations, decelerations, and other temporary changes (round to nearest 5)

What can cause fetal tachycardia?

Maternal fever, dehydration, meds, hyperthyroidism, and earlier/mild hypoxia

What can cause fetal bradycardia?

Severe/prolonged hypoxia, cord prolapse/compression, maternal hypotension and hypoglycemia

What is FHR variability?

Fluctuations in FHR around the baseline, reflecting an intact fetal CNS and oxygenation; moderate variability is good

What can decreased variability indicate?

Fetal sleep, prematurity, meds, OR potentially fetal hypoxia/acidemia

What is reassuring acceleration after 32 weeks?

Increase of >15 bpm lasting >15 seconds but <2 minutes

Intermittent FHR Monitoring

Periodically checking FHR with doppler or fetoscope q15-30 minutes, allows freedom of movement

Continuous Electronic Fetal Monitoring (EFM)

Provides continuous tracing of FHR externally (transducers on abdomen) or internally (FSE)

Accelerations

Temporary increase in FHR above the baseline that are reassuring

Types of Decelerations

Variable, early, late, prolonged decelerations

Variable Decelerations

Abrupt/random decrease in FHR (U, V, W shape) with no relationship to contractions

What causes variable decelerations?

Umbilical cord compression

What causes early decelerations?

Fetal head compression (descent, pushing, crowning)

How do early decelerations appear?

Nadir (lowest FHR) occurs at peak of contraction, mirroring contractions (occurs at same time as contractions)

What causes late decelerations?

Decreased placental perfusion or Uteroplacental insufficiency (decreased fetal oxygenation)

How do late decelerations appear?

FHR decreases after contraction begins with nadir appearing after contraction’s peak

Nursing Intervention for Late Decelerations

Reposition laterally (left), IV fluids, reduce/stop Pitocin, assess cord prolapse, give oxygen, notify provider

Why shouldn’t we give routine oxygen for abnormal FHR when mother already has oxygen?

Giving extra oxygen doesn’t always improve fetal oxygenation as there could be other causes (uteroplacental insufficiency, cord compression, maternal hypotension, excessive oxytocin)

Prolonged Deceleration

A decrease in FHR >15 bpm lasting 2-10 minutes, requires prompt assessment/intervention

What can cause prolonged decelerations?

Cord compression, maternal hypotension, excessive uterine activity, other causes of decreased fetal oxygen

What is required before placing a fetal scalp electrode?

ROM, cervix >2 cm, presenting part low enough

What is a fetal scalp electrode?

Spiral electrode attached to fetal presenting part (scalp) to measure FHR accurately

Contraindications for fetal scalp electrode

HSV, HBV, HIV due to electrode breaking skin

Nonpharmacologic methods to reduce labor pain

Breathing/relaxation, massage, hydrotherapy, ambulation/position changes

What are major concerns with opioids during labor

They cross placenta and can cause maternal and newborn CNS/respiratory depression and decreased fetal FHR variability

Contraindications to Epidural

Hypovolemia, coagulation, sepsis/infection, increased ICP

Nursing considerations for epidurals

Monitor BP and FHR closely; administer IV fluids and avoid prolonged supine positioning

Why monitor FHR after an epidural?

Maternal hypotension from epidurals can decrease uteroplacental perfusion, decreasing FHR

Complications of Epidural

Hypotension, N/V, pruritus, urinary retention, fever, resp. depression, FHR changes

Spinal (intrathecal) Anesthesia

Medication inserted into subarachnoid space with fast onset and short duration, commonly used for C/S (emergency/scheduled)

Concerns after spinal anesthesia

Hypotension and spinal headache

When is pudendal block useful?

During second stage especially for episiotomy or vaginal birth for perineum as well as lower vagina and vulva

Episiotomy

Surgical incision made on perineum to enlarge vaginal opening and maybe reduce time of birth (routine not recommended)

What does local infiltration anesthesia treat?

Pain from perineum due to episiotomy or laceration repair; does NOT relieve uterine contraction pain

When is general anesthesia generally used for birth?

Reserved for emergency C-section when there isn’t enough time for regional anesthesia

What is nitrous oxide used for during labor?

Self-administered inhaled analgesia for pain/anxiety with rapid onset and causes dizziness and nausea

Nursing Considerations for First Stage

Perform full maternal, fetal, physical, psychosocial, and cultural assessment to establish baseline

Nursing Considerations for Second Stage

Support, monitor, coach/educate, and empower the patient while monitoring maternal and fetal status

What should be assessed during second stage?

Maternal VS, FHR, contractions, coping, rectal/perineal pressure, fetal descent, bulging perineum, labial separation, and crowning

What is delayed pushing?

Waiting after complete dilation to allow fetal descent/rotation before actively pushing, sometimes done with epidural

What should nurse do immediately after birth?

Dry and warm the newborn, assess respiratory/condition, assign Apgar scores at 1 and 5 minutes, promote skin to skin and breastfeeding if stable

APGAR

Appearance, Pulse, Grimace, Activity, Respiration (0-2 each)

What medication is commonly given after placental delivery to reduce hemorrhage risk

Oxytocin (Pitocin) to promote uterine contractions that compress blood vessels

What should fundus feel like postpartum?

Firm and midline, generally new/below umbilicus

1st degree laceration

Perineal skin only

2nd degree laceration

Skin + perineal muscle

3rd degree laceration

Skin/muscle + anal sphincter

4th degree laceration

Extends through anal sphincter and into anal wall

What does a boggy fundus indicate?

Poor uterine contraction (atony) and increased risk for hemorrhage; gently massage fundus until firm

What does a fundus displaced to the right suggest?

Full bladder, which can interfere with uterine contraction and contribute to bleeding

Why is bladder assessment important after an epidural?

Reduced sensation can make the patient less aware of bladder fullness and urinary retention

What can indicate a postpartum perineal hematoma?

Severe/excruciating perineal pain, perineal swelling/mass, and sometimes urinary difficulty

Nursing Consideration for Third and Fourth Stage

Monitor for placental separation, prevent postpartum hemorrhage, assess placenta and document, and support immediate newborn care/bonding