Intrapartum Assessment & EFM Interpretation: Focused Nursing Guide

All right, mini lecture number two on intrapartum content. So this is going to be our focused intrapartum assessment

um and our EFM interpretation. So what that looks like um in addition

to the stage and phase of labor that a patient is in, we have specific assessments that we want to do if the

patient is intartum, so in labor or we use these same ones in anapartum. Um, but we'll get to that in anapartum

content and talk about what's the same and what might be a little different. So, these five things are important on

every pregnant woman to assess in addition to our vital signs as part of our basic assessment and then the

interpretation of EFM or electronic fetal monitoring. There are two parts to electronic fetal monitoring. There are

fetal heart rate assessment and then contraction pattern assessment and interpretation.

So the five focused assessment pieces are pain, contractions, leaking of fluid, vaginal bleeding, and fetal

movement. And you can see here to the right I have listed, you know, pain is a subjective assessment. We are going to

ask the patient and then we're we're going to allow them to give us that information. That's not something we can

objectively assess. Contractions, leaking of fluid, and vaginal bleeding. However, we have a subjective assessment

of which we are asking the patient if they're experiencing those things. And then we are able to objectively assess

those um in various ways often as well. So those might be a two-part. And then fetal movement mostly subjective. We're

going to take the patient's response on what um what level of fetal movement they're feeling, whether it's their

normal amount, less, etc. Um but we as examiners can also objectively palpate fetal movement after um the usually

after about 20 weeks or more. Um, so that might also be an objective assessment from time to time. So we want

to split out all of those questions. We're going to talk about what those mean. Um, so when we're assessing pain,

obviously the patient's going to report that. I want to note that we do separate pain and contractions. Um, because the

patient can be having pain somewhere else in their body that is not related to contractions even though they're in

labor. That would also be significant to know. Um, and patients can also have contractions that aren't painful. So

those are two separate assessments. So obviously ask the patient if they're experiencing pain. No, then we move on

from that. If it's a yes, we want to know where the pain is. We want a um rating of the pain on a 0 to10 scale,

descriptors of what the pain feels like. Um and then when did it start? Is there something that exacerbates the pain? Is

there something that makes it better? Have they taken medication for the pain depending on what it is? Um, all of

those can be important factors that we need to take into account when dealing with a patient who

is having pain anywhere else other than a contraction pain kind of uh complaint during labor.

So, contractions again, we're going to very easily start out with a subjective assessment of are they having or feeling

contractions? Yes or no. If yes, we want to know how frequently they feel them, how long they last, which is called the

duration, and then how strong, intense, or painful they are, and when they began. Um, when we're talking about

intensity of contractions, there is obviously the subjective assessment of the patient saying how

strong the contractions are. And there is also um a trick to palpating contractions.

Um, so we want to have our hands on the belly during when the patient is having contraction. usually can palpate as it

uh the muscle tightens and you can palpate when it's at its tightest and it's at its peak and then you can also

feel as it starts to relax when the contraction ends. Um so if you're if you're at the bedside

consistently, you could also objectively even with just palpation assess frequent frequency and duration.

Um but intensity is um very important via palpation. We'll talk about why especially even in conjunction with

fetal monitoring that palpating contractions is important. Um but the general like cheat code rule of thumb is

if you take the tips of your pads of your fingers and you push on the end of your nose um that is what a mild

contraction feels like to palpation. meaning that's how tense or how much rebound you get from the abdomen is the

tip of your nose. Moderate contractions are more like feeling the chin. So if you put the pads of your fingers to your

chin, there's a little less squish, a little more um firmness underneath and that's a moderately palpated

contraction. And then if you put the your finger to your forehead, that is what a strong or intense

contraction palpates like. Um, so the skin is very thin, the muscle underneath is very taut. And that's just kind of a

palpation trick to kind of give you context on the different intensity levels of contraction.

Um, in addition to palpating contractions, it's also really important if your patient is contracting regularly

to palpate their abdomen in between contractions to make sure that they have adequate resting tone. Um that means

that the uterine muscle is relaxing in between contractions. So it should feel nice and soft. Um and that's important

for various reasons and we'll talk about that more with fetal monitoring. Leaking of fluid. So have they

experienced a gush of fluid like their water is broken or you know what we would call have their membranes been

ruptured? Um if no then we don't have to worry about it. If yes then we want to know when their water broke, what color

the fluid was. Um, so obviously we're going to ask our ask the patient if they've experienced that. And then if

they're in labor and they have been we've confirmed that they're ruptured, we can oftent times observe the fluid on

like the chucks pad and so we can also assess for color um and amount. Um, and then obviously we would like the

amiiotic fluid to be free of anything concerning. So ideally that fluid is clear or yellow tinged clear fluid.

Um, we don't like it to be pink or red. That indicates that there is bleeding somewhere. Um, that may or may not be

normal. And we'll talk about bleeding here in a second. Um, we don't want it to be green or bright bright yellow with

a foul odor or anything like that that could indicate infection. We also don't like it to be um like a dark green to

brown where we think it could be monium stained fluid. So, sometimes that occurs as well. So, ideally clear or yellow

tinged is what we're looking for. Vaginal bleeding, if the patient is experiencing vaginal bleeding or not.

Um, no is a great answer and we move on. If if they say yes, how much? When did it begin? And is this like a bright red

bleeding or is it an old brownish leftover kind of um blood? And this is also we're subjectively assessing from

the patient and we are objectively assessing if there is any on the chucks pad or um a perry pad if they're wearing

on one or whatever that might be. We never assume that any vaginal bleeding during pregnancy is normal but it also

doesn't always mean that there's an e situation that needs addressed. Um so there are various other assessment

pieces that we're going to use to help us decide um which route we go when we have vaginal bleeding with pregnancy.

Um the term bloody show very common when a patient is in labor that is commonly mistaken with vaginal bleeding

but it is not true vaginal bleeding and once you've seen the difference it's it's very distinct but bloody show is

more like a pink tinged or pink stained mucusy looking um discharge and that is typically in response to the cervix

dilating and a facing thinning out and with how fryable that tissue is during during labor and delivery. Um it's also

very common for women to report um a little bit of this bloody show after vaginal exams, sterile vaginal exams

where we're manipulating the cervix or if we do a sterile speculum exam and we're irritating the cervix. That that's

a very common um finding. So it's nice to tell patients that that can be expected when we do those kind of exams.

But bright red frank bleeding is never to be assumed normal and it could be coming from various other other places

or other causes. Fetal movement um we need we always ask about fetal

movement for pregnant patients once they are 20 weeks in gestation. So some patients might feel um fetal movement

call quickening really early in pregnancy um or as they get closer to that 20we mark. Once they've reached 20

weeks and from there forward, typically we expect them to feel some sort of fetal movement and be able to report

that. There are some exceptions to that rule. Um especially with anterior placentas um

or other various exceptions, but that's not the rule. They're the exceptions. So, for the most

part, past 20 weeks, we expect the patient to be able to report some type of fetal movement.

We always ask patients someone, are they feeling fetal movement? But if they say anything along the lines of uh not in a

while or less than normal or no, I haven't felt baby move today. Um that is a bright red flag warning sign. Um if

baby isn't moving as much as normal or as much as what they feel like their baseline is or they haven't felt baby

move for an extended period of time. Um we teach fetal kick counts to anopartum during during pregnancy. Um but anytime

any pregnant patient says that they are feeling decreased fetal movement or lack of fetal movement um for an extended

time, we should be assessing them right away. Um if they if they're calling from home to say this, we want

them to come in and be checked out. If they are at the hospital, we want to get out the Doppler or the fetal heart rate

monitor and check on baby, do an ultrasound if we need to. Um and the reason behind that is

fetal movement is highly associated with a non-hypoxic fetus and the rationale for that being if a fetus is lacking

adequate amounts of oxygen. Oxygen is energy to a fetus. So if they do not have adequate oxygenation via the

placenta in the uterus, they will conserve their energy. They will lie very still to conserve what oxygen they

are receiving and use it to keep tissues alive and prioritize because movement is less important than

oxygenation. Um so if a patient reports that they're feeling decreased fetal movement or that they haven't felt baby

move in an extended amount of time, we want to check and make sure that baby is doing okay on the inside. And sometimes

a patient will say something like, "I haven't felt baby move in a while." and then you tell them to, you know, drink

some water, lay down, pay attention, really gave all of your attention to counting baby's movements, and all of a

sudden they're they're moving all over the place. Or they say they don't feel, they come in to get checked out, and as

soon as we stick baby on the monitor, they start moving around. Um, we would always rather

air on the side of caution. And if they truly feel like baby is moving less, I would much rather them come in and get

checked out and us put baby on the monitor and make look and make sure everything's okay, then ignore it. Um,

and it end up with a poor outcome. So, always trust your patient if they report that their baby hasn't been moving as

much as normal. And we're not going to get, this is not the mini lecture which we go deep into

electronic fetal monitoring, but I do just want to touch on the terminology that you guys are going to want to get

familiar with. So I said for EFM that's our electronic fetal monitor. We have two parts to that. One is the fetal

heart rate and the other is contraction monitoring. So with a fetal heart rate we have four categories that we assess.

the fetal heart rate baseline which you can think of as like the average uh variability which is the B2B changes in

the fetal heart rate and then accelerations and decelerations which are changes in the fetal heart rate

periodically dependent upon different things. Contractions also have four categories

that we're looking at. So the frequency, how often they're occurring, duration, how long they last, intensity, which we

talked about a little bit, and then resting tone. So, in between those contractions, making sure that the

abdomen has nice and soft resting tone. And the reason that resting tone is so important is because that is when the

uterus um relaxes and all of the blood flow gets to replenish all the reserves of the fetus in between all of the hard

work and um tension that's being put in place during contraction. So resting tone is very important um because if it

isn't adequate, if it isn't enough in time or the uterus is not relaxing to the degree that it should um baby will

eventually run out of reserve throughout labor and not tolerate the contractions as well if they aren't receiving

adequate time during the resting period. So that is it for our focused intrapartum assessment. We're going to

talk more through each of those five pieces in class, but that should get you started for the week.