Maternal and Fetal assessment during labor

I. IMMEDIATE ASSESSMENT OF A WOMAN IN STAGE 1

Initial interview and Physical examination

Ask about the ff :

EDC

Frequency, duration and intensity of contractions

Amount and character of show

Whether ROM has occurred

Time the woman last ate

Any known drug allergies

Past pregnancy and previous pregnancy history

Her birth plan she has planned such as no analgesia or who will cut the umbilical cord
Assess

V/S

Contractions (frequency, duration, intensity)

Preparedness and readiness for labor

II. DETAILED ASSESSMENT DURING 1ST STAGE OF LABOR

History

Current pregnancy history

Documentation of gravida and para status
Description of this pregnancy
o Planned or not
o Pattern and place of prenatal care
o Adequacy of nutrition
o Whether any complication such as spotting , falls, hypertension of pregnancy, infection or alcohol /drug ingestion
has occurred
Plans for labor
o Does she want any medication for pain
o Will she use breathing exercises
o Will she have a support person with her
Future child care
o Will she breastfeed or formula feed
o Has she chosen a pediatrician
Past pregnancy history
Document prior pregnancies :
o Number , dates , types of birth
o Any complications
o Sex & birth weights of children
What is the current health status of children
Past

health history
Document any previous surgeries (surgical adhesions might interfere with free fetal passage)
Heart disease or DM (special precautions are required during labor and birth)
Anemia (blood loss at birth may be more important than it is usual)
TB (lung lesions may be reactivated at birth by changes in lung contour)
Kidney disease or HTN (BP must be monitored even more carefully than usual)
If she has ever had a STI such as herpes (infant may be exposed to disease by vaginal contact if disease is still active)
Determine whether a womans lifestyle places her at high risk for prescription or nonprescription drug use or HIV exposure

Family Medical history

Ask if any family member has a condition such as :
o Cognitively challenged
o Heart disease
o Blood dyscrasia
o DM
o Kidney disease
o Cancer
o Allergies
o Seizures


Physical examination

o Congenital disorder
Adequate preparation can then be made for a child who might have special needs

Abdominal Assessment
Estimate fetal size by fundal height (should be at the level of xiphoid process at term)
Palpate and percuss bladder area (over symphysis pubis) to detect full bladder
Assess for abdominal scars to reveal previous abdominal or pelvic surgery that could have left adhesions
Inspect lower extremities for skin turgor to assess hydration and also for edema and varicose veins
o Women with large varicosities are more prone to thrombophlebitis after birth
o Severe edema suggests hypertension of pregnancy

Leopolds maneuvers

A systematic method of observation and palpation to determine fetal presentation and position

Assessing rupture of
membranes

When ROM occurs, a woman feels a sudden gush of amniotic fluid from her vagina ; it feels as if she has lost bladder
control
In other women, ROM is subtle , occurring as a slow loss of fluid ; there may be question of whether the membranes have
ruptured
Vaginal examination
o Using a sterile speculum usually reveals whether amniotic fluid is present in vagina
o After vaginal secretions are obtained (usually with the use of sterile, cotton-tipped applicator) , test them with a
strip of Nitrazine paper
- vaginal secretions are usually acid ; Amniotic fluid is alkaline
- if amniotic fluid has passed through vagina recently , pH of vaginal fluid will probably be alkaline (>6.5) when
tested by nitrazine paper (appears blue-green or gray to deep blue)
- a false reading may occur in woman with intact membranes who has a heavy, bloody show because blood is also
alkaline
o Fern test
- examination of vaginal secretions under a microscope
- because of its high estrogen content, amniotic fluid will show a fern pattern when dried and examined in this way;
urine will not
If womans membranes ruptured at home, ask her to describe color of amniotic fluid
o Should be clear as water
o Yellow-stained
- may indicate a blood incompatibility bet mother and fetus
- amniotic fluid is bilirubin stained from breakdown of RBC
o Green fluid suggests meconium staining
- normal in breech births because of buttocks compression
- may indicate fetal anoxia in vertex presentation
- fetus needs immediate assessment
- infant will need continuing close assessment after birth to rule out possible meconium aspiration

Vaginal examination

Assessment of pelvic
adequacy

Ultrasound

Vital signs

Necessary to determine :
o Extent of cervical effacement and dilatation
o Fetal presentation , position, and degree of descent
May be done during contractions or during contractions
o More of the fetal skull may be palpated during a contraction because cervix retracts more at that time
o Examination during contraction is more painful
o Palpation of membranes during a contraction when they are under pressure may cause them to rupture
After finishing vaginal examination , plot the new degree of dilatation and descent of presenting part on a labor progress
graph
Do not conduct this in presence of fresh bleeding , because this may indicate a placenta previa is present ; doing so might
tear placenta and cause hemorrhage resulting in danger to both mother and fetus
Using internal conjugate and ischial tuberosity
Generally done during pregnancy so that by weeks 32-36 of pregnancy , nurse-midwife or physician is alerted that a CPD
could occur
Whether the pelvis is wide enough to allow fetus to pass through the internal diameters can be reassessed during early
labor
Involve vaginal manipulation and discomfort so they are not retaken if already obtained
Suprapubic angle may be estimated early in labor to determine how readily fetal head will be born
o If angle is too steep , fetal head can lock behind it and perineal tissue may tear during birth as fetal head is
pushed posteriorly
o To estimate this angle, place the fingers vaginally and pres up against the pubic arch
o If fingers cannot be separated in this position , the angle is unusually steep ( < 90 degrees)
May be used at term to determine diameters of fetal skull and to determine presentation, presenting part, position, flexion,
and degree of descent of a fetus

Pulse and Respiration

Should be measured and recorded q 4 h during labor
Pulse may be rapid on admission because she is nervous and anxious
A persistent PR of > 100 bpm suggests tachycardia from dehydration or hemorrhage

RR during labor is usually 18-20 breaths per min

Do not count RR during contractions because women tend to breath rapidly from pain
If a woman is using controlled breathing to decrease pain in labor, her RR could be abnormally slow
Observe for hyperventilation (rapid, deep respirations)
o Prolonged hyperventilation leads to the blowing off of CO2 and accompanying symptoms of dizziness and tingling
of hands and feet
o Rebreathing into a paper bag to reverse

Blood pressure
Usually measured and recorded q 4 h during labor
Always measure bet contractions both for womans comfort and for accuracy because BP tends to rise 5 to 15 mm Hg during
a contraction
An increase in BP may indicate development of pregnancy-induced hypertension
A decrease in BP or a decrease in pulse pressure may indicate hemorrhage
If woman receives analgesic agent (eg. mepiridine) that tends to be hypotensive , check her BP app 15 min after
administration to be certain that extreme hypotension is not occurring
Laboratory Analysis
Assessment of uterine
contractions

III. INITIAL FETAL ASSESSMENT

Auscultation of Fetal heart sounds

IV. ELECTRONIC MONITORING

External Electronic
monitoring
Internal electronic
monitoring
Telemetry
Fetal Heart rate and Uterine contraction records
I. FETAL HEART RATE PATTERNS

Baseline fetal heart

rate
Variability
Periodic changes

Sinusoidal Fetal heart

Rate pattern
II. OTHER ASSESSMENT TECHNIQUES

Scalp stimulation

Done by applying pressure with fingers to the fetal scalp through the dilated cervix
Causes a tactile response in fetus that momentarily increases FHR

Fetal Oxygen saturation

level

If fetus is in distress and becoming acidotic , FHR acceleration will not occur
An assessment of acid-base balance in fetus

May be measured by an O2 sat sensor that is introduced into the uterus and placed beside the fetuss
cheek after membranes have ruptured
Measurement gen reserved for women who have an internal contraction or fetal monitor already in place

Fetal blood sampling

May reveal hypoxia in a fetus before it becomes apparent on an ECG or external monitoring system
Invasive
Reserved only for a fetus at high risk

Skill Leopolds Maneuvers

1. Prepare the pt
Explain the procedure
Instruct pt to empty her bladder

Position woman supine with knees slightly flexed . Place a small pillow
or rolled towel under one side
Wash hands using warm water

Observe womans abdomen for longest diameter and where fetal

movement is apparent

2. Perform the first maneuver (determines whether fetal head /breech is in

fundus)
Stand at the foot of the pt , facing her and place both hands flat on
her abdomen
Palpate the superior surface of fundus. Determine consistency, shape
and mobility

3. Perform the second maneuver (locates the back of fetus)

Face the pt and place the palms of each hand on either side of
abdomen
Palpate the side of the uterus. Hold the L hand stationary on the L
side of uterus while the R hand palpates the opposite side of uterus
from top to bottom . Then hold the R hand steady , and repeat
palpation using L hand on L side
4. Perform the third maneuver (determines part of fetus at the inlet and its
mobility)
Gently grasp the lower portion of abdomen just above symphysis
pubis bet thumb and index finger and try to press the thumb and
finger together . Determine any movement and whether part is firm
or soft
5. Perform the fourth maneuver (determines fetal attitude and degree of
fetal extension into the pelvis ; should be done only if fetus is in cephalic
presentation
Place fingers on both sides of uterus app 2 inch above the inguinal
ligaments , pressing downward and inward in the direction of the
birth canal . Allow fingers to be carried downward

Explanation reduces anxiety and enhances cooperation

Doing so promotes comfort and allows for more productive palpation
because fetal contour will not be obscured by a distended bladder
Flexing the knees relaxes abdominal muscles ; using pillow or towel tilts the
uterus off the vena cava , thus preventing supine hypotension syndrome
Handwashing prevents the spread of possible infection . Using warm water
ads in pts comfort and prevents tightening of abdominal muscles
The longest diameter (axis) is the length of the fetus . The location of
activity most likely reflects position of feet

Proper positioning of hands ensures accurate findings

When palpating , a head feels more firm than breech . A head is round and
hard ; breech is less well defined . Head moves independently of body ;
breech moves only in conjunction with body

Proper positioning of hand ensures accurate findings

One hand will feel a smooth , hard, resistance surface (back) while on the
opposite side, a number of angular nodulations (knees and elbows of fetus)
will be felt

If the presenting part moves upward so an examiners hands can be

pressed together, the presenting part is not engaged (not firmly settled
into pelvis) . If part is firm, it is the head ; If soft , then it is breech

The fingers of one hand will slide along the uterine contour and meet no
obstruction , indicating back of the fetal neck . The other hand will meet
an obstruction an inch or so above the ligament , this is the fetal brow .
Position of fetal brow should correspond to the side of uterus that
contained elbows and knees of fetus. If fetus is in poor attitude, examining
fingers will meet an obstruction on the same side as the fetal back i.e the
fingers will touch the hyperextended head . If the brow is very easily
palpated (as if it lies just under the skin) fetus , probably in a posterior
position (occiput is pointing toward womans back)