What are the RN assessments when caring for a patient in active labor?

What are the RN assessments when caring for a patient in active labor?

In tending to a patient, an RN conducts several assessments in order to achieve the well-being of the mother and the baby when in active labor. Here are the primary assessments:Here are the primary assessments:

 1. Maternal Vital Signs

 Blood Pressure: They should be monitored constantly so as to assess the development of hypertension or hypotension.

 Heart Rate: Tachycardia as well as bradycardia should be sought for.

 Temperature: Monitor for fever because infection may occur in the child.

 2. Uterine Contractions

 Frequency, Duration, and Intensity: In measuring the contractions, you should employ the use of a tocometer or electronic fetal monitoring device.

 Pattern: To check the pattern of the contraction, one need to evaluate the pattern of the contraction to determine if they are developing in the right manner.

 3. Fetal Heart Rate (FHR)

 Baseline: These are 110-160 per minute.

 Variability: Assess for the amount of variation which is in fact good for the wellbeing of the fetus.

 Decelerations: Listen for any sign of any decelerations that can be a sign of fetal distress.

 4. Cervical Dilation and Effacement

 Dilation: Source: Merriam-Forbes SC (2012) Assess the dilation of the cervical opening to ascertain the degree of labor.

 Effacement: Relative to pregnancy, determine how much thinned the cervix is, often expressed in per cent.

 5. Fetal Presentation and Position

 Presentation: At this point, distinguish the position of fetal head, breech or any other presentation that may be present.

 Position: Evaluate fetal position with the help of Leopold’s maneuvers (e. g. in LOA position, the fetal back is directed towards the fundus –occipitoanterior or towards the right or left sacro-lumbar –occipitoposterior).

 6. Amniotic Fluid

 Color and Consistency: Record the appearance of the amniotic fluid either clear, meconium-stained or blood-streaked and the thickness or thinness, of the fluid when the membranes rupture.

 Amount: Evaluate the amount of this fluid if there is any belief of oligohydramnios or polyhydramnios.

 7. Pain Management

 Pain Levels: Take the patient’s vitals and assess the level of pain using a particular pain rating scale.

 Interventions: Offer or arrange pain management, whether this is medicinal, for example an epidural, or otherwise such as breathing exercises.

 8. Labor Progression

 Labor Curve: Keep track of the progress of labor in relation to the partogram or labor curve chart and check for signs of straying from standard patterns.

 9. Patients’ Comfort and Dealership of Comfort

 Emotional State: Be supportive and also clear any concerns or paranoia as this may raise his/her feeling of anxiety level.

 Comfort Measures: Calm the patient and make sure they are comfortable and offer the patient any help needed in changing position and relaxation.

 10. Laboratory and Diagnostic Tests

 Laboratory Tests: Supervise for blood tests that includes Hb/Hct and WBC count in case need be.

 Diagnostic Tests: Be ready to do the test whenever required even if the test is fetal scalp stimulation or blood tests.