Intrapartum Care Skills PEARSON PDF

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Summary

Intrapartum Care - amniotomy procedure, epidural anesthesia procedure, fetal external electric monitoring procedure, etc...

Description

NUR 113: Intrapartum Care Notes Amniotomy – a procedure that intentionally ruptures the amniotic sac to induce labor o

NOT delegated to UAP but can request the UAP to report pt observations for follow up

o

Must review MD’s orders and obtain signed informed consent from pt

o

Explain to the pt about the procedure - why it is necessary & how the pt can participate

*Assess fetal heart rate prior to, during, and following amniotomy because rupturing the amniotic membranes changes the pressure inside the uterus and causes risk of a prolapsed cord 

During procedure – IMPORTANT! o

Once the membranes are ruptured and fluid is seen – note the color, amount, odor, and presence of meconium or blood  

amniotic fluid should be clear or slightly cloudy & without any odor

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meconium stained or bloody amniotic fluid places the fetus at risk for complications

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foul smelling fluid may indicate an infection

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absent, decreased, or increased amounts of amniotic fluid may indicate fetal stress

o

Maternal temperature should be assessed every 2h or more frequently if febrile and/or ordered 

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high temp might indicate intrauterine infection (chorioamnionitis)

Post-procedure: Document

Epidural anesthesia – used to lessen sensation in the lower body by blocking nerve impulses from the lower spine o

NOT delegated to the UAP but can request the UAP to report pt observations for follow up

o

Must review MD’s order and notify anesthesia personnel & obtain signed informed consent from pt

o

o 

Explain about potential side effects (headache, hypotension) 

Inform the pt that they should report the onset of a headache

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Inform the pt of frequent blood pressure assessments

Explain to the pt about the procedure - why it is necessary & how the pt can participate

During procedure – IMPORTANT! o

Obtain maternal baseline VS, fetal heart rate, and variability

o

Administer an IV fluid bolus per facility policy before the epidural is begun to avoid hypotension

o

Assist and support the woman in position = side-lying with knees flexed or sitting up on side of bed with back flexed

o

BP, HR, and fetal HR are assessed before the test dose, every 5 min during the test dose and at the end of the test dose

o

Have ephedrine at bedside in case of hypotensive or fetal bradycardia episode

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Assess the bladder for distention every 30 min because a full bladder can slow the descent of the fetus and risk damage to the bladder

o

Change positions at least every hour to maximize uteroplacental blood flow, increase circulation, promote comfort, and avoid a one-sided block

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Post-procedure: Document

Fetal External Electronic Monitoring – used to listen to, see visual configurations, and record or print rhythm strips of the fetal heartbeat through the abdomen of the mother o

NOT delegated to the UAP but can request the UAP to report pt observations for follow up

o

Must review MD’s orders and explain to the pt about placing monitor belts around the abdomen – why it is necessary, how the pt can participate & how the results will be used in planning further care or treatments

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During procedure – IMPORTANT! o

Have pt empty her bladder

o

Place the tocodynamometer (“toco”) over the uterine fundus off the midline on the area palpated to be firmest during contractions (the area of greatest contractility)

o

Resting tone tracing (without UC) = 10 or 15 mmHg pressure line  adjust the line to reflect this

o

Apply the ultrasonic gel to the diaphragm of the ultrasound transducer & place the diaphragm on the maternal abdomen in the midline between the umbilicus & the symphysis pubis

o

Listen for the FHR (will have a whip-like sound) & move the diaphragm laterally if necessary to obtain a stronger sound

o

When the FHR is located, attach the second elastic belt snugly to the transducer

*FHR tracing provides information about fetal status and response to the stress of labor  nonreassuring characteristics allows prompt interventions 

Post-procedure: Document

Fetal Heart Rate: Auscultating – provides information about the health of the fetus and how the fetus responds to changes in the uterus environment o

NOT delegated to the UAP but can request the UAP to report pt observations for follow up

o

Review MD’s orders and explain to the pt that you are going to listen to the FHR using a Doppler – why it is necessary & how the pt can participate

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During procedure – IMPORTANT! o

Check the pt’s pulse against the fetal sounds you hear – if the rates are the same, reposition the Doppler 

If rates are not similar, count the FHR for 1 full minute (FHR has a double rhythm and only one sound is counted)

 o

If FHR cannot be located, move the Doppler laterally

Auscultate the FHR between, during, and for 30 seconds following uterine contractions 

Low-risk women: every 30 min in the first stage and every 15 min in the second stage

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High-risk women: every 15 min in the first stage and every 5 min in the second stage

*FHR is heard most clearly through the fetal back. Locate the fetal back using the Leopold maneuvers

Fetal Internal Scalp Electrode Placement: Monitoring – (for better electronic monitoring of the FHR) electrode may be placed internally after the amniotic sac has ruptured & the cervix has opened during labor o

NOT delegated to the UAP but can request the UAP to report pt observations for follow up

o

Must review MD’s orders and obtain signed informed consent from pt

o

Pt’s membranes must have already ruptured spontaneously or been ruptured by the healthcare provider 

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Generalist RNs are not allowed to rupture membranes

During procedure – IMPORTANT! o

Explain the procedure, purpose, and implications of using a fetal scalp electrode to pt

o

Assist the pt into lithotomy position

o

Perform vaginal exam to determine dilation and presentation of the fetus

*Contraindications: membranes are not ruptured, the cervix is not dilated at least 2 cm, there is a reason a cervical examination cannot be done, there is a diagnosed infectious risk to the fetus, the presenting part is unknown, and the presenting part is not down against the cervix o

Apply fetal scalp electrode on a firm area of the fetal vertex (avoid fontanelles, face, genitals, etc)

o

Connect spiral electrode wire to a leg plate & secured by a self-adhesive grounding pad to the mother’s inner thigh

o

Verify FHR is tracing before discontinuing the intermittent or continuous external monitor

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To remove  disconnect the electrode wire from the cable & rotate the lead counterclockwise (once removed make sure it is intact) 

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Post-procedure

If unable to remove, tape electrode wire to the mother’s thigh and notify surgeon!...