NCM104_Maternal-and-Fetal_Assessment_Tia.pdf

Maternal And Fetal Assessment M ar y Winrose B. Tia , RN , M A M SN 01 Maternal and Fetal Assessment The basic goal of maternal- fetal assessment is to detect any conditions present in mother or fetus that may adversely effect the pregnancy...

Maternal And Fetal Assessment M ar y Winrose B. Tia , RN , M A M SN 01 Maternal and Fetal Assessment The basic goal of maternal- fetal assessment is to detect any conditions present in mother or fetus that may adversely effect the pregnancy outcome. It includes several procedures, including detailed interview, Leopold’s maneuver, ultrasound, fetoscopy, nonstress test and cardiotocography (CTG) 01 What is Leopolds Maneuver? It is a systematic way to determine the position of a fetus inside the uterus. it utilizes palpation and observation which provides information about the number of fetuses, identity of the presenting part, fetal line and attitude.  What is Leopolds Maneuver? Named after the Maneuver is preferably gynecologist Christian performed after 24 weeks Gerhard Leopold gestation when fetal outline can be already palpated  Leopold’s Maneuver The maneuvers are not truly diagnostic. Actual position can only be determined by ultrasound performed by a competent technician or professional.  PURPOSES 1. Systematically observing and palpating the abdomen to: a. determine of what is in the fundus b. evaluate the fetal back and extremities c. palpate the presenting part above the symphysis d. determine the direction and degree of flexion of the head  PURPOSE 2. To aid in location of fetal heart rates 3. To determine single versus multiple gestation 4. The data provide the general and specific information that can be used to plan care during the antepartum and intrapartum periods.  FACTORS AFFECTING PERFORMING THE PROCEDURE 1. Difficult to perform in Obese patients. 2. Women with hydramnios 3. Women with full bladder  PROCEDURE Introduce self and Rationale establish rapport a. Explanation reduces a. Explain the procedure to anxiety and enhances the client cooperation  INTERVIEW Classify pregnancy status Using the GTPAL (stands for gravida, term, preterm, abortion and living) Rationale - To describe a female patients’ obstetrical history. History helps us on how to set plan for quality nursing intervention to our patients.  INTERVIEW Obtain the expected date of birth - EDD or EDC (Using the Rationale Naegele’s Rule). Age of a. This will give you the gestation (AOG), Including the estimated due date and fetal growth estimate. gestational age of the patient. b. Estimating fetal growth is essential for monitoring the health and development of the fetus during pregnancy. LABOR WATCH M ar y Winrose B. Tia , RN , M A M SN  TIMING OF CONTRACTION To monitor the progress of women’s labor REMEMBER!!!! You will need a watch, or clock, with a second hand and a labouring woman!  DEFINITIONS Contractions – is a rhythmic tightening of the musculature of the upper uterine segment that begins mildly and becomes very strong late in labor  DEFINITIONS The duration of the During labor, the duration uterine contraction is the of the contractions will time from the beginning of start out short (25 to 35 one contraction to the end seconds long) and of that same contraction ultimately get to 70 – 90 seconds long.  DEFINITIONS DURATION With this progression from shorter contractions to longer contractions, a mother can figure out if this is real labor, or simply Braxton Hicks contractions. Braxton Hicks contractions remain irregular and do not get progressively longer as time passes.  DEFINITIONS FREQUENCY The frequency of the This not only includes the contractions is measured duration of one contraction, from the beginning of one but also the rest period contraction to the beginning between the two. So if you of the very next have a contraction at 8 contraction. pm and it lasts for 60 seconds, and then you have another contraction at 8:15 pm, the contractions have a duration of 60 seconds and a frequency of 15 minutes.  DEFINITIONS INTENSITY The intensity of the contractions also changes as labor progresses. Early labor contractions are often described as mild menstrual cramps. Contractions in later labor, have been described by some stand-up comedians as feeling like your lower lip was stretched up over your head! While this analogy is humorous, it is true that with normal labor, the intensity of the contractions does increase, and this is a good sign that labor is progressing well.  DEFINITIONS INTENSITY Mild - the uterus is contracting but does not become more than minimally tense (tip of the nose) Moderate - the uterus feels firm (chin) Strong - the contraction is so intense that the uterus feels as hard as wood at the peek of contraction (forehead)  PROCEDURE (labor watch) 1. Explain the procedure to 2. Assist patient to a the patient comfortable position with pillow on her head.  PROCEDURE 3. Sit on one side of the 4. Rest hand on the bed facing the patient. abdomen of the women in labor.  PROCEDURE 5. Do the labor monitoring..  SAMPLE Date/time Vital signs FHT Frequency / Remarks duartion 7/26/14 @ T - 36.8 C 138 bpm ? / 30 sec. mild 8:00 am P - 89 bpm R – 18 cpm Bp – 120/80 mmHg 8:15 am T - 36.8 C 140 bpm 15 min./ 40 sec. moderate P - 95 bpm R – 18 cpm Bp – 120/80 mmHg  PROCEDURE Assess for signs and symptoms of labor. Rationale a. To identify if patient is having true or false labor and to assess as well the progress of labor.  INTERVIEW Perform a detailed interview on the current pregnancy history. Include the following: Description of present pregnancy (intended or not, place or pattern of prenatal care, adequacy of nutrition, presence of any complications such as spotting, falls, hypertension, infection, alcohol or drug ingestion during pregnancy) Plans for labor. (Does she want to have the baby naturally? Who will be her support person?) Plans for childcare. (Will she breastfeed? Has she chosen a primary health provider? If baby is boy, does she want him circumcised?)  INTERVIEW Obtain history of prior pregnancies, abortions, miscarriages, including number, dates, and types of birth, any complications, and outcomes, including health, sex, and birth weights of previous children.  INTERVIEW Obtain past health history. Include the following: Surgeries and/ or blood transfusion. Cardiac, renal, respiratory, metabolic and/or any systemic diseases Infection and/or exposure to infection Blood type. If Rh (-) ask if she has received Rh immune globulin (RhIG/ RhoGAM).  INTERVIEW Ask for family medical history including the pattern of inheritance of the following: Mental and neuromuscular problem Cardiac, respiratory, metabolic and renal problem Hematologic diseases  PREPARATION Prepare the client Rationale Explain the procedure and Explaining the procedure instruct the client to empty enhances cooperation and the bladder reduces anxiety. Emptying the bladder promotes comfort and allows for more productive palpation because a distended bladder will obscure fetal contour.  PREPARATION Prepare the client Rationale Wash your hand using warm Hand washing prevents the water spread of possible infection. Using warm water aids in client’s comfort and prevents tightening of the abdominal muscles.  PREPARATION Prepare the client Rationale a) Drape the client properly. a) To provide client’s privacy Prevent unnecessary b) To provide comfort for the exposure client. b) Place a small pillow under c) Flexing the knees relaxes the client’s head the abdominal muscles c) Position the woman supine with knees slightly flexed. Place a small pillow or rolled towel under her left side. Note: If the Nurse is R handed, stand at the woman’s R side facing her for the first 3 steps, then turn and face her feet for the last step (L handed, stand at left side)  PREPARATION Prepare the client Rationale g. Observe the woman’s g. The longest diameter abdomen for longest (axis) is the length of the diameter and where the fetus, the location of fetal movement is activity most likely apparent reflects the position of the feet.  IMPLEMENTATION FIRST MANEUVER 1. Stand on the foot of the bed facing her, and placing both hands flat on her abdomen. 2. Palpate the surface of the fundus, determine the consistency, shape and mobility. 3. Expecting to palpate a soft, irregular mass in the upper quadrant of the maternal abdomen. Also known as the Fundal Grip  FIRST MANEUVER FINDINGS The fetal head is round and hard, and moves independently of the trunk. The soft mass is the fetal buttocks, it is symmetric, and has small bony processes; unlike the head, it moves with the trunk.  SECOND MANEUVER 1. Face the client and place the palms of each hand on either side of the client’s abdomen 2. While the right hand is placed steady, palpate the opposite side of the abdomen from top to bottom using the left hand. 3. Do the same to the other side of the abdomen using the right hand to palpate the side while the left palm is place steady. Known also as Lateral and Umbilical Grip  SECOND MANEUVER FINDINGS On one side of the abdomen, you will palpate round nodules; these are the fists and feet of the fetus (Kicking and movement are expected to be felt).  The other side of the abdomen feels smooth; this is the fetus’s back  THIRD MANEUVER 1. While facing the client Gently grasp the lower portion of the abdomen just above the symphysis pubis between the thumb and the third finger together (to determine the presenting part). 2. Determine any movement whether the part is soft or firm also known as Pawlick’s Grip  THIRD MANEUVER FINDINGS The unengaged is round, firm, and ballottable The buttocks are soft and irregular Soft, presenting part at the symphysis pubis indicates Breech presentation.  FOURTH MANEUVER 1. Face the client’s feet. 2. Place your hand on the client’s abdomen, and point your fingers toward the mother’s feet. 3. Then try to move the hands toward each other while applying downward pressure. Pelvic Grip  FOURTH MANEUVER FINDINGS If the hands move together easily, the fetal head has not descended into the maternal pelvic inlet If the hands do not move together and stop to resistance met, the fetal head is engaged into the pelvic inlet.  FOURTH MANEUVER FINDINGS If you palpated the buttocks in the fundus, then you should feel for the head. If one cannot feel the head, then it probably has descended into the pelvic inlet.  PROCEDURE Auscultate fetal heart sounds. Take a one-full minute of fetal heart beat Document pertinent findings, including the quadrant where you obtained the FHT. THANK YOU!