A. ASSESSMENT
1. Health History
a. Elicit a description of symptoms, including onset, duration, location and precipitating factors or events. Cardinal signs and symptoms may include:
- A sudden gush of fluid from the vagina
- Any copious vaginal bleeding
- Presence of uterine contractions with or without abdominal pain
- Decreased fetal movement
b. Explore maternal and family history for risk factors fro intrapartum complication.
- Age younger than 18
- History of preterm labors
- Poor obstetric history
- Multiple pregnancy
- Hydramnios
- Smoking
- Poor hygiene
- Poor nutrition
- Employment
Family risk factors may include:
- History of diabetes
- History of complications of birth in other family members.
c. Assess the family’s responses to high-risk pregnancy, labor, and a potential crisis situation.
d. Assess maternal, paternal, and family bonding, and the potential for perinatal loss and grief.
2.Physical Examinations
a. Vital signs
- Measure maternal blood pressure, pulse and respirations in the presence of vaginal fluid leakage, or bleeding to assess for infection.
- Measure maternal vital signs to identify presence of shock.
- Monitor fetal heart rate (FHR) to determine fetal status.
b. Inspection
- Inspect the perineum for characteristics of vaginal discharge. Observe for color, odor, consistency, and amount
- Observe size and shape of the uterus
- At delivery, visually inspect the placenta for abnormal characteristics.
c. Palpation
- Monitor uterine activity to determine progress of labor.
- Evaluate the cervix for readiness for, or progress in, labor. Do not perform a vaginal examination if bleeding is present.
3.Laboratory and diagnostic studies
a. Ultrasound is used to determine fetal status, localize the placenta, and determine amniotic fluid volume.
b. Kleihauer-Betke or fetal cell blood test is used to determine whether the blood cells are maternal or fetal. Maternal cells remain colorless when stained. Fetal cells become purple-pink when stained.
c. Nitrazine test tape and presence of ferning are used to determine if there is rupture of the amniotic sac. Nitrazine paper turns green-blue in the presence of amniotic fluid. On microscopic examination of a sample of fluid, a ferning pattern, similar to frost on window, appears on the dried slide. This is characteristic of a high-estrogen fluid.
d. Electronic urine monitoring will demonstrate the presence of uterine contractions.
e. Complete blood count will document the presence of anemia infection.
B. NURSING DIAGNOSIS
- In addition to complication-specific diagnosis, the following nurses diagnoses are common to care of the at-risk intrapartum client.
1. Anxiety
2. Fear
3. Ineffective Compromised Family Coping
4. Anticipatory Grieving
5. Self-Esteem Disturbance
6. Spiritual Distress
7. Knowledge Deficit
8. Pain
9. Risk for Injury
C. PLANNING AND OUTCOME IDENTIFICATION
1. Threats to optimal physical and emotional pregnancy outcome will be determined.
2. The client will be physically comfortable, and the client and family will have a healthy response to their high-risk pregnancy status and potential complications.
3. The client and family will understand their pregnancy complication and the necessary treatment.
D. IMPLEMENTATION
1. Assess maternal and fetal physiologic status to detect early maternal and fetal changes requiring early intervention.
a. Perform ongoing assessment during the intrapartum period.
b. Expect the unexpected, and be prepared to provide critical care nursing if needed.
c. Accurately document the assessed problem and subsequent nursing interventions and their effectiveness.
2. Provide physical emotional support
a. Observe the client and family for emotional response and ability to cope with discomfort and pain.
b. Provide comfort measures.
c. Coordinate physical care for client with emotional needs of the client and family.
d. Assess and support the client’s and family’s psychosocial and emotional needs, particularly in relation to potential loss and grief.
e. Encourage and support coping mechanisms, including aspects of loss and grief.
E.OUTCOME EVALUATION
1. The client and fetus maintain normal physiological status; any deviations that arise are identified and corrected early.
2. The couple demonstrates greater comfort, decreased fear and anxiety, increased used of coping techniques.
3. The client and partner express understanding of their pregnancy complication and the necessary procedures to be performed.