Comprehensive Labor and Delivery Nursing Assessment & Interventions: Lecture 3

What is the purpose of assessing a laboring patient?

To determine if they are in labor, the well-being of the mother and fetus, and whether admission is necessary.

What are the three key assessments for a laboring patient?

1) How is MOM coping? 2) How is FETUS coping? 3) How is UTERUS coping?

What is the significance of oxytocin administration after the baby's shoulder is born?

Oxytocin should be given after the anterior shoulder is delivered, requiring clear interprofessional communication.

What are the options for administering oxytocin?

IM: 10 IU (easy, no IV needed); IV: 5 IU IV push (works faster, preferred if access is available).

Why is oxytocin considered a high alert medication?

It is a powerful drug that can cause life-threatening complications, necessitating extra checks and clear communication.

What is an en caul birth?

It is when a baby is delivered still inside the unbroken amniotic sac, considered rare and often special in many cultures.

What key information should be collected during history taking in labor?

Pregnancy details, medical and social history, allergies, substance use, and serology/lab work.

What routine labs are typically done for a woman in labor?

CBC, Type & Screen, and Urine Dip/Urinalysis.

What does CBC stand for and what does it assess?

Complete Blood Count; it assesses hemoglobin/hematocrit for blood loss risk, WBC for infection, and platelets for safety in procedures.

What does the Type & Screen lab test ensure?

It ensures blood is available for transfusion if needed during labor.

What are the four ways to describe a contraction?

Intensity, frequency, duration, and resting tone.

How is contraction intensity assessed by palpation?

Mild = tip of nose, Moderate = chin, Strong = forehead.

What is the normal frequency of contractions during labor?

About 1 contraction every 2-3 minutes, with no more than 5 in 10 minutes.

What is the typical duration of contractions in active labor?

Approximately 60-90 seconds.

Why is it important to assess contractions during labor?

To check the baby's well-being, ensure labor is progressing normally, and detect any potential problems.

What differentiates true labor from false labor?

True labor contractions are stronger, regular, and cause cervical change, while false labor contractions are irregular and do not cause dilation.

What vital signs should be assessed for the mother during labor?

Blood pressure, temperature, pulse, and respiratory rate, with expected variations due to labor.

What should be assessed regarding the mother's coping strategies during labor?

Pain management techniques and overall coping mechanisms.

What is the importance of assessing the fetal heart rate (FHR) during labor?

To evaluate the fetus's coping and well-being during contractions.

What are some signs of fetal compromise during labor?

Abnormal FHR patterns, decreased fetal movement, and maternal distress.

What is the role of the prenatal sheet in labor assessment?

To provide essential information about the patient's pregnancy history and previous care.

What should be done if the prenatal sheet is missing?

Request it from the provider's office or gather as much information directly from the patient.

What does the term 'dilation' refer to in labor assessment?

The opening of the cervix as labor progresses.

What is the significance of monitoring the mother's voiding pattern during labor?

To assess hydration status and potential complications affecting fetal descent.

What are some potential complications of unnecessary medical interventions during labor?

They can interrupt the body's natural processes, leading to increased risks for both mother and baby.

What is the purpose of assessing the uterine resting tone?

To ensure the uterus is soft between contractions, indicating proper recovery and blood flow.

What is Uterine Tachysystole?

Excessive contractions within a short time frame, defined as more than 5 contractions in a 10-minute period, lasting longer than 90 seconds, with a resting tone of less than 30 seconds.

Why is Uterine Tachysystole harmful?

It can lead to a potential decreased oxygen supply to the baby if not managed properly.

What are common causes of Uterine Tachysystole?

Labor stimulating medications (like oxytocin), chorioamnionitis (infection), and hydramnios.

What is the first nursing intervention for Uterine Tachysystole?

Stop or reduce uterotonic agents.

What position should the mother be in to improve uteroplacental perfusion?

Reposition the mother to the lateral (left) side.

What is the purpose of continuous FHR monitoring during Uterine Tachysystole?

To watch for late decelerations, bradycardia, or abnormal variability and notify the provider if non-reassuring FHR patterns persist.

How is contraction frequency measured non-electronically?

By timing the start of one contraction to the start of the next using a watch.

What does the Intrauterine Pressure Catheter (IUPC) measure?

It measures frequency, duration, and intensity of uterine contractions directly from inside the uterus.

What criteria must be met to use an IUPC?

Membranes must be ruptured, the cervix must be dilated to 2 cm, and a skilled practitioner must be available.

What is the purpose of the Tocodynamometer (Toco)?

It measures the frequency and duration of contractions as part of the external fetal monitoring system.

What does cervical dilation indicate?

How open the cervix is, measured in centimeters from 0 to 10 cm, with 10 cm indicating full dilation.

What is cervical effacement?

The thinning and shortening of the cervix, described in percentages from 0% to 100%.

What does fetal station refer to?

How far the baby's head has descended into the pelvis, measured in relation to the ischial spines.

What are the types of rupture of membranes (ROM)?

SROM (spontaneous), AROM (artificial), PROM (premature), and PPROM (preterm premature).

What does the 'COAT' acronym stand for in assessing amniotic fluid?

Color, Odor, Amount, and Time of rupture.

How do you confirm rupture of membranes (ROM)?

Using a Nitrazine swab or a ferning test to differentiate between ROM and urine.

What is the normal fetal heart rate range?

110-160 bpm.

What are the two main methods for assessing fetal heart rate?

Intermittent Auscultation (IA) and Electronic Fetal Monitoring (EFM).

What is the significance of fetal accelerations?

They indicate a temporary rise in fetal heart rate, usually occurring with contractions.

What is fetal bradycardia?

A fetal heart rate below 110 bpm for 10 minutes.

What is fetal tachycardia?

A fetal heart rate above 160 bpm for 10 minutes.

What does a sterile vaginal examination assess during labor?

Cervical dilation, effacement, fetal station, presentation and position, membrane status, and other observations.

What is the difference between dilation and effacement?

Dilation refers to the opening of the cervix (0-10 cm), while effacement refers to the thinning of the cervix (0-100%).

What are the potential risks of using an IUPC?

Uterine perforation, infection, and abruptio of the placenta.

What is Intermittent Auscultation (IA) used for?

IA is used for low-risk laboring women to provide intermittent data about fetal heart rate (FHR) correlated with contractions.

What should be listened for after a contraction during IA?

Listen for a full minute after a contraction to assess the fetal heart rate; a rate of 80 may indicate a possible late deceleration.

What is the purpose of Leopold's Maneuvers?

Leopold's Maneuvers are used to assess the position, presentation, and lie of the fetus, as well as to locate the fetal back for heart tone assessment.

What are the characteristics of the fetal head and buttocks during palpation?

The head feels like a round, firm ball that rolls easily, while the buttocks are softer and wider.

What is External Fetal Monitoring (EFM)?

EFM is a non-invasive, continuous monitoring method for the baby's heart rate and uterine contractions, using two belts on the mother's abdomen.

When is EFM typically used?

EFM is used in high-risk pregnancies, such as during induction or when epidurals are administered.

What are the two main components assessed by EFM?

EFM assesses fetal heart rate (baseline, variability, accelerations, decelerations) and uterine contractions (frequency and duration).

What is supine hypotension syndrome?

Supine hypotension syndrome occurs when a pregnant woman lies on her back, causing compression of the inferior vena cava and aorta, leading to decreased blood flow and potential fetal hypoxia.

What symptoms indicate supine hypotension syndrome?

Symptoms include decreased blood pressure, tachycardia, diaphoresis, nausea and vomiting, lightheadedness, and dizziness.

What is the best position for a laboring woman to avoid supine hypotension syndrome?

The left lateral position is preferred to relieve pressure on the inferior vena cava.

What is a Continuous Fetal Scalp Electrode?

A tiny spiral wire placed on the baby's scalp to provide a direct reading of the fetal heart rate, used when the baby is in a vertex position and the cervix is dilated with ruptured membranes.

What is an Intrauterine Pressure Catheter (IUPC)?

An IUPC is a device inserted into the amniotic space to measure uterine contractions, requiring ruptured membranes and a dilated cervix.

What are the benefits of Intermittent Auscultation (IA)?

IA allows for mobility during labor and provides useful information about fetal heart rate in low-risk situations.

What should be done before performing Leopold's Maneuvers?

The patient should empty their bladder and lie supine with knees slightly bent, using a small towel under the hip.

How is fetal heart rate best auscultated?

Fetal heart tones are best auscultated through the back of the fetus.

What is the significance of fetal heart rate variability?

Fetal heart rate variability is an important indicator of fetal well-being.

What factors can affect the accuracy of external fetal monitoring?

Maternal obesity and excessive movement can hinder the effectiveness of external fetal monitoring.

What is the first step in applying EFM?

Apply gel to the abdomen before placing the FHR transducer over the baby's back.

What is the purpose of monitoring contractions during labor?

Monitoring contractions helps assess their frequency, duration, and intensity, which are crucial for evaluating labor progress.

What should be done if a fetus is in vertex presentation?

Place the stethoscope in the right or left lower quadrant of the abdomen to best hear the fetal heart rate.

What should be done if a fetus is in breech presentation?

Place the stethoscope near the umbilicus to best hear the fetal heart rate.

What is the importance of patient teaching during fetal monitoring?

Patient teaching is essential to ensure understanding and support for the laboring patient and their support persons.

What is the role of the RN when preparing for a laboring woman with twins?

The RN should determine the correct placement of the external fetal monitor to capture the heart rates of both fetuses.

What is the normal range for baseline fetal heart rate (FHR)?

110-160 bpm

What does moderate variability in FHR indicate?

A healthy nervous system and good oxygenation.

What is the significance of accelerations in FHR?

They indicate the fetus is well-oxygenated.

What does bradycardia in FHR mean?

A baseline FHR <110 bpm lasting for 10 minutes, indicating potential fetal distress.

What does tachycardia in FHR indicate?

A baseline FHR >160 bpm lasting for 10 minutes, which can signal distress due to various causes.

What are the types of decelerations in FHR?

Early, variable, and late decelerations.

What is the first step in interpreting an EFM strip?

Identify the baseline FHR.

What does absent variability in FHR suggest?

No detectable fluctuations, which may indicate fetal distress or CNS depression.

What is considered minimal variability in FHR?

Fluctuations ≤5 bpm around the baseline.

What does marked variability in FHR mean?

Fluctuations >25 bpm, which may indicate stress or other concerns.

What is the clinical significance of minimal variability lasting longer than 40 minutes?

It is concerning and may require intervention.

What is the '15 x 15 rule' for accelerations in FHR?

An acceleration is ≥ 15 bpm above baseline, lasting at least 15 seconds but < 2 minutes.

What could cause tachycardia in a fetus?

Infection, medications, maternal dehydration, or fetal hypoxemia.

What does the presence of decelerations in FHR indicate?

Decreases in heart rate that need to be assessed for type and cause.

How should you assess FHR variability?

In a 1-minute section on the strip with no accelerations, decelerations, or contractions.

What does moderate variability in FHR reflect?

A good balance between sympathetic and parasympathetic activity, indicating adequate oxygenation.

What is the significance of persistent marked variability?

It can indicate fetal stress, especially if paired with recurrent decelerations.

What does a reactive non-stress test (NST) indicate?

≥ 2 accelerations in a 20-minute period, which is reassuring.

What is the definition of absent variability?

No detectable fluctuations in the FHR baseline, concerning when combined with decelerations.

What factors can affect FHR variability?

Fetal sleep, maternal medications, hypoxemia, and CNS anomalies.

What is the role of Leopold's maneuver before IA and EFM?

To determine the location of the fetal heart.

What should be done to prepare a patient for FHR assessment?

Put the patient in a supine position and have them empty their bladder.

What does the presence of accelerations during contractions indicate?

It suggests the fetus is responding well and is well-oxygenated.

What is the clinical significance of a fetal heart rate that stays within the normal range?

It usually means the baby is well-oxygenated.

What is the '15 x 15 rule' for fetal heart rate accelerations?

An acceleration is defined as ≥ 10 bpm above baseline, lasting at least 10 seconds for fetuses < 32 weeks gestation.

What triggers fetal heart rate accelerations?

They commonly occur with fetal movement, vaginal exams, or in response to contractions.

What does the presence of accelerations indicate?

It suggests no evidence of hypoxia or acidosis at that moment.