Assessment And Re-Assessment Of Women In Labor Including Immediate PostpartumTITLE:
Assessment And Re-Assessment Of Women In Labor Including Immediate Postpartum
PURPOSE:
In Labor
To evaluate status of labor, including a description of uterine activity, cervical dilatation and effacement, fetal status and presentation.
Postpartum
To evaluate obstetric patients during the postpartum period.
CONDITION/APPLICABILITY
This policy applies to all OB /GYNE medical, Nursing and Midwifery staff.
DEFINITIONS:
Assessment : Assessment of specified maternal and fetal parameters on regular bases e.g. Every 2 hours
POLICY:
The OB/GYNE resident/specialist shall evaluate the patient on admission and document every assessment in the progress notes. In an emergency situation a midwife can examine the patient.
Initial assessment must be done by the OB/GYNE resident for the patient in L&D within one hour of the arrival and inform the registrar /senior registrar and reassessment according to the situation by OB/GYNE specialist or resident. Refer to the LAD -045
PROCEDURE:
In Labor
Assessment should be documented and the following information should be included:
6.1.1.Maternal Assessment:
6.1.1.1.maternal vital sign
6.1.1.2.abdominal assessment include clinical fetal weight estimation
Uterine tenderness and duration ,strength and frequency of contraction
6.1.1.3.Vaginal examination should be done by OB resident/
specialist.
6.1.1.3.1.For primigravida, every 4 hours.
6.1.1.3.2.For multigravida, every 2 hours.
61.1.3.3.Frequent examinations may be indicated in the
following cases:
a. Unsatisfactory CTG
b. Suspected inadequate uterine contractions
c. Uncertain presentation or position.
d. Urge to push or other signs of second stage
6.1.2.Fetal assessment
6.1.2.1. Assesses the fetal weight clinically
6.1.2.2. ultrasound fetal viability placenta cord insertion ,liquor fetal biometry and fetal weight estimation
6.1.2.3. CTG. Refer to LAD -024
Immediate postpartum and up to 24 hours
check the following every 15 minutes for hour, then every 30 min for the 2nd hrs.; then every 4 hours x 24 hours.
Check vital signs (blood pressure, pulse, temperature, respiration),
Examination
6.2.2.1.abdominal examination including uterine fundus convolution
6.2.2.2.vaginal examination inspect the vulva and examine the vagina to detect increasing pain, bleeding, edema, hematoma and breakdown of episiotomy.
any swelling and amount of lochia following the delivery.
6.2.2.3.for the patient post Cesarean section check the following
6.2.2.3.1.Check status of dressings and report any significant drainage or
discharge to the OB resident or specialist.
6.2.2.3.2.Observe for the urinary output; should be at least 30 ml/hr. urine
should be clear yellow or a light straw color.
6.2.2.3.3.Inspect the amount and character of lochia, noting any clots.
6.2.2.4.Encourage the patient to void and ambulate within 1 hrs for postpartum and
8 hrs post cesarean section .
6.2.2.5.Increase frequency of assessment if hypo-tonic uterus or abnormal bleeding
noted. Abnormal findings which may require intervention include fundus
above the umbilicus, fundus deviated to right or left, fundus soft to palpation,
presence of clots, bleeding which soaks one or more pads.
Inspect the extremities for edema, and varicose vein.
6.2.2.7.Assessment (Vaginal examination) and documentation must be done for all
normal delivery patients by OB/GYNE resident /SR before shifting to
postnatal ward and at the time of discharge from hospital.
6.2.2.8.Any complicated delivery weather extended episiotomy or post instrumental
delivery assessment should be done by senior registrar/consultant before
shifting to postnatal ward .
RESPONSIBILITY:
OB/GYNE Doctors
OB/GYNE Nurses and Midwifes
L and D nurse/midwife
FORMS/ EQUIPMENTS
Peri-operative Record sheet
L and D Nursing Admission sheet
Progress note.
REFERENCE:
Care of Patients in Postpartum, Vanderbilt University Medical Center
Introductory Maternity and Pediatric Nursing by N.Jane Klossner and Nancy Hatfield
REVISION:
APPROVALS: