A. Maternal Assessment
1. A complete health history should include.
a. Name
b. Age
c. Physician
d. Weight
e. Allergies
f. Blood type and Rh factor
g. Previous medical conditions
h. Prenatal problems
i. Gravida and para status
j. Estimated date of delivery
k. Prenatal education
l. Method of newborn feeding
2. Screening to risk factors is essential and should include:
a. Bleeding
b. Premature of membranes (if ruptured, determine time of the note color and odor, if any)
c. Hydramnios
d. Abnormal presentations
e. Multiple gestations
f. Prolapsed cord
g. Preparations labor
h. Meconium, stained amniotic fluid
i. Fetal heart irregularities
j. Postmaturity
3. Physical Assessment
a. Material vital signs, weight, and cardiac and respiratory status are monitored. The frequency of maternal vital signs and respiratory status assessment is as follows.
- First stage latent: Blood pressure (BP), pulse, and respirations are assessed every hour (if the BP is greater than 140/90 or if the pulse is greater than 10, contact the primary care provider). Temperature is assessed every 4 hours (every 2 hours if the membranes are ruptured)
- First stage active: BP, pulse, and respirations are assessed every hour.
-First stage transition: BP and respirations are assessed every 30 minutes.
-Second stage: BP, and pulse are assessed every 5 to 15 minutes.
b. Fundal height is measured.
c. Status of labor (that is, contractions [onset, frequency, duration, and intensify], membranes, bleeding, cervical dilation, and fetal descent) is determined.
d. The client’s need for comfort, analgesia, or anesthesia is assessed continuously (see section III and IV).
