Professional Documents
Culture Documents
13
Applicable to
Approved by
Sandra Smith, RN Robin Mutz, RNC, MPPM
Manager, Labor and Delivery Administrative Director, Womens Patient Care Center
Table of Contents
I. Purpose: ........................................................................................1
II. Policy:...........................................................................................1
III. Additional Competencies Required: ............................................2
IV. Specific Information:....................................................................2
V. Clinical Implications: .................................................................14
VI. Documentation: ..........................................................................14
VII. References: .................................................................................15
VIII. Contributors:...............................................................................16
IX. Endorsements: ............................................................................16
I. Purpose:
II. Policy:
Qualified personnel collaboratively provide care for obstetric patients during the
initial assessment and triage period.
A. Initial assessment:
b. Fetal status
i. Fetal movement (as applicable)
ii. Fetal heart rate (as applicable)
Page 2 of 16
Vanderbilt University Medical Center Policy Number AS 201111-20.13
Policy Manual Effective Date December 2010
Chapter: Area Specific Practice Guidelines Supersedes September 2004
c. Labor status
i. Uterine contractions including date and time of
onset and frequency
ii. Membrane status including date and time of rupture
and characteristics of fluid, if applicable
f. Patient interview
2. Fetal status
Page 3 of 16
Vanderbilt University Medical Center Policy Number AS 201111-20.13
Policy Manual Effective Date December 2010
Chapter: Area Specific Practice Guidelines Supersedes September 2004
3. Labor status
a. Review prenatal record for results of last cervical exam
b. Palpate abdomen for tenderness, resting tone, and uterine
contractions
c. Perform digital cervical exam (in the absence of vaginal
bleeding or known placenta previa) to include
determination of dilatation, effacement, position, and
consistency.
d. Patient may ambulate for up to one hour following 20
minute fetal monitor strip if tracing is Category I, fetus is
vertex and well applied to cervix and patient is otherwise
stable.
e. If indicated, recheck the patients cervix in one hour to
assess for cervical change.
f. A woman experiencing contractions is in true labor unless a
physician, certified nurse midwife, or qualified nurse
practitioner or physician assistant acting within his or her
scope of practice, certifies that, after a reasonable time of
observation, the woman is in false labor.
g. Certified Nurse Midwives, and Nurse Practitioners are
approved and designated by the Medical Center Medical
Board as Qualified Medical Personnel (QMPs) as defined
by EMTALA and may provide medical screening
examinations and certification of false labor as part of their
scope of practice in the Maternal Special Care Unit, Labor
and Delivery Unit, outpatient/obstetric clinics and/or when
called to the Emergency Department
Page 4 of 16
Vanderbilt University Medical Center Policy Number AS 201111-20.13
Policy Manual Effective Date December 2010
Chapter: Area Specific Practice Guidelines Supersedes September 2004
2. Fetal status
a. If gestational age is less than 24 weeks, auscultate fetal
heart rate
b. If gestational age is greater than or equal to 24 weeks,
obtain an initial 20 minute fetal monitor strip to evaluate
for baseline rate and periodic patterns. Continue
monitoring as specified in policy Fetal Heart Rate
Monitoring.
c. If evaluation extends greater than 40 minutes without
appropriate fetal reassurance then treatment plan is per
attending provider.
d. Patients with >28 weeks EGA should have a reactive NST
prior to discharge or other fetal reassurance per provider
discretion.
e. Assist provider in obtaining fetal fibronectin and/or
cultures as indicated prior to cervical exam.
f. Determine fetal presentation by cervical exam, Leopolds,
or ultrasound (performed by provider) if indicated.
3. Labor status
a. Review prenatal history for information regarding previous
cervical exams and prescribed measures for preterm labor.
b. Palpate uterus for tenderness, resting tone and uterine
contractions.
c. Place toco and obtain monitor strip for uterine contraction
assessment.
d. Evaluate patient for vaginal discharge, loss of fluid or
vaginal bleeding.
Page 5 of 16
Vanderbilt University Medical Center Policy Number AS 201111-20.13
Policy Manual Effective Date December 2010
Chapter: Area Specific Practice Guidelines Supersedes September 2004
2. Fetal Status
a. If gestational age is less than 24 weeks, auscultate fetal
heart rate
b. If gestational age is greater than or equal to 24 weeks,
obtain an initial 20 minute fetal monitor strip to evaluate
for baseline rate and periodic patterns. Continue
monitoring as specified in policy Fetal Heart Rate
Monitoring.
c. If evaluation extends greater than 40 minutes without
appropriate fetal reassurance then treatment plan is per
attending provider.
Page 6 of 16
Vanderbilt University Medical Center Policy Number AS 201111-20.13
Policy Manual Effective Date December 2010
Chapter: Area Specific Practice Guidelines Supersedes September 2004
3. Labor status
a. Palpate uterus for tenderness, resting tone and uterine
contractions.
2. Fetal Status
a. If gestational age is less than 24 weeks, auscultate fetal
heart rate. For patient reassurance, provider may choose to
perform an ultrasound.
b. If gestational age is greater than or equal to 24 weeks,
obtain fetal reassurance appropriate to gestational age.
i. If 24-28 EGA, Biophysical Profile (BPP) performed
by provider.
ii. If > 28 EGA NST, BPP, or reassurance per provider
discretion.
3. Labor status
a. See Nursing Management of the Labor Patient, if
applicable.
Page 7 of 16
Vanderbilt University Medical Center Policy Number AS 201111-20.13
Policy Manual Effective Date December 2010
Chapter: Area Specific Practice Guidelines Supersedes September 2004
2. Fetal Status
a. If gestational age is less than 24 weeks, auscultate fetal
heart rate.
b. If gestational age is greater than or equal to 24 weeks,
obtain an initial 20 minute fetal monitor strip to evaluate
for baseline rate and periodic patterns. Continue
monitoring as specified in policy Fetal Heart Rate
Monitoring. If ruptured continue electronic fetal monitoring
until fetal reassurance ascertained and absence of labor
confirmed.
c. If evaluation extends greater than 40 minutes without
appropriate fetal reassurance then treatment plan is per
attending provider.
d. Patients with >28 weeks EGA should have a reactive NST
prior to discharge or other fetal reassurance per provider
discretion.
e. A limited ultrasound may be performed by provider if
indicated, i.e. unable to confirm rupture with speculum
exam, uncertain presentation, transport patient.
3. Labor status
a. Palpate abdomen for tenderness, resting tone and uterine
contractions
b. Perform cervical exam for the following indications:
i. Frequent contractions
ii. To rule out labor
iii. Severe pain
iv. Significant change in patient status
v. Persistent variable fetal heart rate decelerations
Page 8 of 16
Vanderbilt University Medical Center Policy Number AS 201111-20.13
Policy Manual Effective Date December 2010
Chapter: Area Specific Practice Guidelines Supersedes September 2004
2. Fetal Status
a. If gestational age is less than 24 weeks, auscultate fetal
heart rate
b. If gestational age is greater than or equal to 24 weeks,
obtain an initial 20 minute fetal monitor strip to evaluate
for baseline rate and periodic patterns. Continue
monitoring as specified in policy Fetal Heart Rate
Monitoring.
Page 9 of 16
Vanderbilt University Medical Center Policy Number AS 201111-20.13
Policy Manual Effective Date December 2010
Chapter: Area Specific Practice Guidelines Supersedes September 2004
3. Labor status
a. See Nursing Management of the Labor Patient, if
applicable.
Page 10 of 16
Vanderbilt University Medical Center Policy Number AS 201111-20.13
Policy Manual Effective Date December 2010
Chapter: Area Specific Practice Guidelines Supersedes September 2004
2. Fetal Status
a. If gestational age is less than 24 weeks, auscultate fetal
heart rate
b. If gestational age is greater than or equal to 24 weeks,
obtain an initial 20 minute fetal monitor strip to evaluate
for baseline rate and periodic patterns. Continue
monitoring as specified in policy Fetal Heart Rate
Monitoring.
c. If evaluation extends greater than 40 minutes without
appropriate fetal reassurance then treatment plan is per
attending provider.
d. Patients with >28 weeks EGA should have a reactive NST
prior to discharge or other fetal reassurance per provider
discretion.
3. Labor status
a. See Nursing Management of the Labor Patient, if
applicable.
Page 11 of 16
Vanderbilt University Medical Center Policy Number AS 201111-20.13
Policy Manual Effective Date December 2010
Chapter: Area Specific Practice Guidelines Supersedes September 2004
2. Fetal Status
a. If gestational age is less than 24 weeks, auscultate fetal
heart rate
b. If gestational age is greater than or equal to 24 weeks,
obtain an initial 20 minute fetal monitor strip to evaluate
for baseline rate and periodic patterns. Continue
monitoring as specified in policy Fetal Heart Rate
Monitoring. Note: fetal tachycardia may be related to
maternal dehydration.
c. If evaluation extends greater than 40 minutes without
appropriate fetal reassurance then treatment plan is per
attending provider.
d. Patients with >28 weeks EGA should have a reactive NST
prior to discharge or other fetal reassurance per provider
discretion.
3. Labor Status
a. Apply toco and obtain a 20 minute strip to assess for
presence of uterine contractions
Page 12 of 16
Vanderbilt University Medical Center Policy Number AS 201111-20.13
Policy Manual Effective Date December 2010
Chapter: Area Specific Practice Guidelines Supersedes September 2004
2. Fetal Status
a. If gestational age is less than 24 weeks, auscultate fetal
heart rate.
b. If gestational age is greater than or equal to 24 weeks
monitor for a minimum of four hours following incident. If
contractions are present then evaluation should be extended
to 24 hours.
c. Obtain fetal reassurance appropriate for gestational age
prior to discharge.
i. If 24-28 EGA, Biophysical Profile (BPP) performed
by provider.
ii. If > 28 EGA NST, BPP, or reassurance per provider
discretion.
d. Refer to policy Fetal Heart Rate Monitoring.
3. Labor Status
a. Palpate uterus for tenderness, resting tone and uterine
contractions.
b. Place toco and obtain monitor strip for uterine contraction
assessment.
Page 13 of 16
Vanderbilt University Medical Center Policy Number AS 201111-20.13
Policy Manual Effective Date December 2010
Chapter: Area Specific Practice Guidelines Supersedes September 2004
V. Clinical Implications
VI. Documentation:
Page 14 of 16
Vanderbilt University Medical Center Policy Number AS 201111-20.13
Policy Manual Effective Date December 2010
Chapter: Area Specific Practice Guidelines Supersedes September 2004
VII. References:
Kennedy, B.B., Ruth, D.J., & Martin, E.J. (Eds). (2009). Intrapartum
management modules (4th ed.). Philadelphia: Wolters Kluwer/Lippincott Williams
& Wilkins.
Simpson, K.R. & Creehan, P.A. (Eds) (2008) Perinatal Nursing (3rd ed.).
Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.
Page 15 of 16
Vanderbilt University Medical Center Policy Number AS 201111-20.13
Policy Manual Effective Date December 2010
Chapter: Area Specific Practice Guidelines Supersedes September 2004
VIII. Contributors:
IX. Endorsements:
Page 16 of 16