Intrapartal Assessment Page 1

Intrapartal Assessment Page 1

Middle Georgia College Department of Nursing Labor and Delivery Care Plan Today’s Date_______11/12/2009____________ Client’s Age____28 years_____ weeks_______

EDD________11/16/2009________

G______T______P______A______L_______ Blood type _____B+______

Admission Date________11/12/2009____________ Weeks of Gestation_____39.2

Marital Status________single___________

Allergies_____________NKDA_____________________________

Date prenatal care was initiated________04/15/2009________________ Childbirth classes attended: [ X] yes

[ ] no

If yes, where__________NA____________

Breast or Bottle feeding? ________Bottle___________ # of hours in: Stage 1______3.5 hrs.._____ Stage 2_____30 min______

Weight gain during preg? ______18 lbs_____

Stage 3_____15 min.______ Stage 4________2 hrs.___

Type of anesthesia used: ______________Epidural______________________________________ Risk factors in client’s pregnancy that may affect the labor and delivery process: Client was a gravida 8 and her last 4 pregnancies averaged 1 year apart. __________________________________________________________________________ Complications that have occurred during labor and delivery:__________None_______________ ___________________________________________________________________________ List below medications taken at home:

List below medications taken at the hospital Fentanyl 2 mcg/ml Ropivacaine

Bupivacaine 40%- 10 ccs Pitocin None

Intrapartal Assessment Page 2

STAGES OF LABOR STAGE I: EARLY/LATENT PHASE (Cervical Effacement/Dilatation/Descent) SAFE TIME FRAMES: 1) Primigravida ASSESSMENT CRITERIA 1. Contractions: a) Frequency b) Intensity c) Duration d) Rhythm 2. Cervix: a) Effacement b) Dilatation 3. Descent/Station:

8.6 hrs.

ASSESSMENT DATA

2) Multigravida 5.3 hrs. NURSING INTERVENTIONS

a) Initially q 10-15 minutes

1) Palpate every 30 min.

b) mild

2) Applied toco to abdomen to monitor contractions.

c) 45-50 sec. d) irregular 2. a) 40- 50 % effaced

3) IV fluids Ringers Lactate started via # 18 canula in right forearm 4) Pitocin 10 units/ ml in 500 ccs RL started @ 3 cc/hr @ 0800

b) 4 cm dilated 3) Station -1 and engaged.

6) Patient encouraged to void every 2 hrs. or as needed 7) Assisted pt. to bathroom where she voided 250 ccs clear yellow urine.

4. Bloody Show:

5. Amniotic Membranes:

6. Vital Signs:

7. Fetal Heart Rate:

8. Pain/Comfort Measures:

4)Pt. had small amt. of mucus and bloody show on chuck

8) Assisted in cleaning pt. up and applying new chuck under her.

5) Dr. Das visited, did vaginal exam and used amnihook to rupture membranes. Small amt. of clear liquid passed. Large amt of clear fluid passed when pt. started back to bed.

9) FHR up to 144 bpm when AROM performed.

6) Blood Pressure-118/76 Pulse- 81 Respirations- 18 Temperature- 97.7 axillary 7) Baseline 135 b/m with no decels and moderate variability. 8) Pt. states she is starting to feel some of her contractions but pain level is only a 2 on scale of 1-10.

10) Talked with patient about what type if any pain control measures she wishes to have. She stated she had Epidural with first 2 deliveries but had nothing with her last 5. She states she does not know if she wants one this time. 11) Pt. encouraged to make decision about the insertion of Epidural for pain control 12) Notified anesthetist of pt. decision to have epidural catheter insertion. 13) Pitocin ^ to 6 cc/hr @0830 14. Assisted pt. into sitting position with back arched to facilitate the start of spinal

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9. Client Behaviors & General 9) Pt, tolerated epidural cath Appearance: insertion well. 10.Family Support Measures:

10) Pt.’s female cousin at bedside for moral support. Client talkative with no sign of distress.

anesthesia. Epidural started by anesthetist with no complications or difficulty. 14) # 18 F/C inserted with 400 ccs clear yellow urine returned. Connected to bedside drainage bag. 15) Pitocin ^ to 9 cc/hr 0910

STAGE I: ACTIVE PHASE (Cervical Effacement/Dilatation/Descent) SAFE TIME FRAMES:

1) Primigravida

2) Multigravida. .

ASSESSMENT CRITERIA 1. Contractions: a) Frequency b) Intensity c) Duration d) Rhythm 2. Cervix: a) Effacement b) Dilatation 3. Descent/Station: 4. Bloody Show:

5. Amniotic Membranes:

6. Vital Signs:

7. Fetal Heart Rate:

8. Pain/Comfort Measures:

9. Client Behaviors & General

ASSESSMENT DATA

NURSING INTERVENTION

b) moderate

1) Monitored frequency and intensity of contractions every 30 minutes 2) Reported progression to attendant

c) 60- 70 seconds

3)Palpated abdomen during contraction

1) a) every 4 minutes

d) regular 2) a) 80 % effaced b) 8 cm dilated complete dilatation at 11:14 3) Engaged @ 2 station @ 3 station in vertex position @ 1045 4) No increase in bloody show but still draining mucus and clear liquid. 5) Ruptured 6) 120/ 70- BP 75 bpm – 18 respirations 98.3 F axillary 7) 150 and regular Assessed pt. contraction and pain level. States she is feeling pressure but no pain. Noted baby’s head crowning

4) Vaginal exam performed by RN 5) Assisted pt. to lie on left side to increase comfort level. 6) Changed chuck and cleaned perineal area. 7) Massaged pt. shoulders and back. 3000 ccs RL has infused in order to maintain pt.’s hydration. 8) Monitor for pain. States she only feels a little pressure in perineal area but no c/o pain 9) Pt. has no c/o pain 10) Pt. assisted to get into lithotomy position. 11) Encouraged pt. to push while CNM does perineal massage. 12) Encouraged to breathe deep and push 13) Encouraged pt. to rest between contractions

Intrapartal Assessment Page 4

SAFE TIME FRAMES:

1) Primigravida

2) Multigravida. .

ASSESSMENT CRITERIA Appearance:

10.Family Support Measures:

ASSESSMENT DATA

CNM assesses descent of baby. Continues to push anterior cervix up to facilitate descent

NURSING INTERVENTION

Holding pt.’s legs with knees flexed to chest. Pt. pushed 4 times and delivered baby @ 11:16 with no difficulty. Cord clamped and cut by CNM. Noted gush of bloody liquid along with expulsion of fetus, Pt. cousin at bedside

STAGE I: TRANSITIONAL PHASE (Cervical Effacement/Dilatation/Descent) SAFE TIME FRAMES: 1) Primigravida ASSESSMENT CRITERIA 1. Contractions: a) Frequency b) Intensity

ASSESSMENT DATA Assessed for descent of placenta Assessed uterine fundus

c) Duration d) Rhythm 2. Cervix: a) Effacement b) Dilatation 3. Descent/Station: 4. Bloody Show:

5. Amniotic Membranes: 6. Vital Signs: 7. Fetal Heart Rate:

Assessed bleeding. Noted to have moderate amt. OF DARK RED DRAINAGE.

2) Multigravida NURSING INTERVENTIONS Placenta delivered @ 1120 with no complications. Added 20 mu of Pitocin to 1000 CC bag of RL. Fundus firm at umbilicus Fundal massage performed. Cleaned pt. perineal area and changed bed and applied perineal pad. Offered ice chips.

Intrapartal Assessment Page 5

SAFE TIME FRAMES: 1) Primigravida ASSESSMENT CRITERIA

8. Pain/Comfort Measures:

9. Client Behaviors & General Appearance:

10.Family Support Measures:

ASSESSMENT DATA

2) Multigravida NURSING INTERVENTIONS

Intrapartal Assessment Page 6

STAGE II: BEGINS WITH COMPLETE CERVICAL DILATATION AND ENDS WITH BIRTH SAFE TIME FRAMES: ASSESSMENT CRITERIA

1) Primigravida ASSESSMENT DATA

2) Multigravida NURSING INTERVENTION

1. Contractions: a) Frequency b) Intensity c) Duration d) Rhythm 2. Descent/Station: 3. Bloody Show: 4. Vital Signs:

5. Fetal Heart Rate: 6. Episiotomy: 7. Pain/Comfort Measures:

8. Client Behaviors & General Appearance:

9. Family Support Measures:

11.Immediate Care of the Neonate:

Foley cath discontinued with 600 ccs clear yellow urine in bag.

Intrapartal Assessment Page 7

STAGE III: PLACENTAL SEPARATION SAFE TIME FRAMES: 1)Primigravida & Multigravida ASSESSMENT CRITERIA

ASSESSMENT DATA

1. Signs of Placenta Separation: a) Fundus

NURSING INTERVENTION Assisted back into supine position. No c/o pain

b) Umbilical Cord Resting well with minimal amt. of bleeding noted.

c) Bleeding 2. Placental Delivery: a) Schultze Mechanism b) Duncan Mechanism 3. Vital Signs:

4. Medications Given:

5. Appearance/Behavior:

DELIVERED placenta with shiny side up. Placenta completely expelled with membrane around it. 136/84- BP 80- pulse 18 respirations 97.8 F

Intrapartal Assessment Page 8

STAGE IV: IMMEDIATE RECOVERY PAST DELIVERY SAFE TIME FRAMES: 1)Primigravida & Multigravida ASSESSMENT CRITERIA 1. Vital Signs:

ASSESSMENT DATA .

2. Fundus:

3. Lochia:

Minimal lochia rubra noted on pad

4. Bladder: Bladder soft and nondistended 5. Episiotomy/perineum/rectum: No tearing noted to perineum 6. Medications Given:

7. Appearance/Behavior:

8. Measures to Promote Attachment/Bonding:

9. Pain:

Pt. comfortable lying in bed.

Baby wrapped and laid in mama’s.

No c/o pain

NURSING INTERVENTION Fundus firm at umbilicus