Intrapartal Assessment Page 1

Middle Georgia College

Department of Nursing
Labor and Delivery Care Plan

Today’s Date_______11/12/2009____________ Admission Date________11/12/2009____________

Client’s Age____28 years_____ EDD________11/16/2009________ Weeks of Gestation_____39.2

weeks_______

G______T______P______A______L_______ Marital Status________single___________

Blood type _____B+______ Allergies_____________NKDA_____________________________

Date prenatal care was initiated________04/15/2009________________

Childbirth classes attended: [ X] yes [ ] no If yes, where__________NA____________

Breast or Bottle feeding? ________Bottle___________ Weight gain during preg? ______18 lbs_____

# of hours in: Stage 1______3.5 hrs.._____ Stage 3_____15 min.______

Stage 2_____30 min______ Stage 4________2 hrs.___

Type of anesthesia used: ______________Epidural______________________________________

Risk factors in client’s pregnancy that may affect the labor and delivery process:

Client was a gravida 8 and her last 4 pregnancies averaged 1 year apart.
__________________________________________________________________________

Complications that have occurred during labor and delivery:__________None_______________

___________________________________________________________________________

List below medications taken at home: List below medications taken at the hospital

Fentanyl 2 mcg/ml
Ropivacaine
Bupivacaine 40%- 10 ccs
Pitocin
None

STAGES OF LABOR
STAGE I: EARLY/LATENT PHASE (Cervical Effacement/Dilatation/Descent)
SAFE TIME FRAMES: 1) Primigravida 8.6 hrs.
ASSESSMENT CRITERIA ASSESSMENT DATA
1. Contractions:
a) Frequency a) Initially q 10-15 minutes
b) Intensity b) mild
c) Duration
c) 45-50 sec.
d) Rhythm
d) irregular
2. Cervix:
a) Effacement 2. a) 40- 50 % effaced
b) Dilatation
b) 4 cm dilated
3. Descent/Station: 3) Station -1 and engaged.
4. Bloody Show: 4)Pt. had small amt. of mucus
and bloody show on chuck
5) Dr. Das visited, did vaginal
5. Amniotic Membranes: exam and used amnihook to
rupture membranes. Small
amt. of clear liquid passed.
Large amt of clear fluid
passed when pt. started back
to bed.
6. Vital Signs: 6) Blood Pressure-118/76
Pulse- 81
Respirations- 18
Temperature- 97.7 axillary
7) Baseline 135 b/m with no
7. Fetal Heart Rate: decels and moderate
variability.
8) Pt. states she is starting to
8. Pain/Comfort Measures: feel some of her contractions
but pain level is only a 2 on
scale of 1-10.
Intrapartal Assessment Page 2
2) Multigravida 5.3 hrs.
NURSING INTERVENTIONS
1) Palpate every 30 min.
2) Applied toco to abdomen to monitor
contractions.
3) IV fluids Ringers Lactate started via # 18
canula in right forearm
4) Pitocin 10 units/ ml in 500 ccs RL started
@ 3 cc/hr @ 0800
6) Patient encouraged to void every 2 hrs.
or as needed
7) Assisted pt. to bathroom where she
voided 250 ccs clear yellow urine.
8) Assisted in cleaning pt. up and applying
new chuck under her.
9) FHR up to 144 bpm when AROM
performed.
10) Talked with patient about what type if
any pain control measures she wishes to
have. She stated she had Epidural with
first 2 deliveries but had nothing with
her last 5. She states she does not know
if she wants one this time.
11) Pt. encouraged to make decision about
the insertion of Epidural for pain control
12) Notified anesthetist of pt. decision to
have epidural catheter insertion.
13) Pitocin ^ to 6 cc/hr @0830
14. Assisted pt. into sitting position with
back arched to facilitate the start of spinal
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9. Client Behaviors & General 9) Pt, tolerated epidural cath anesthesia. Epidural started by anesthetist
Appearance: insertion well. with no complications or difficulty.

14) # 18 F/C inserted with 400 ccs clear

10.Family Support Measures: 10) Pt.’s female cousin at yellow urine returned. Connected to
bedside for moral support. bedside drainage bag.
Client talkative with no sign 15) Pitocin ^ to 9 cc/hr 0910
of distress.

STAGE I: ACTIVE PHASE (Cervical Effacement/Dilatation/Descent)

SAFE TIME FRAMES: 1) Primigravida 2) Multigravida.
.

ASSESSMENT CRITERIA ASSESSMENT DATA NURSING INTERVENTION

1. Contractions: 1)
1)
a) Frequency a) every 4 minutes Monitored frequency and intensity of
contractions every 30 minutes
b) Intensity b) moderate 2) Reported progression to attendant
c) Duration
c) 60- 70 seconds 3)Palpated abdomen during contraction
d) Rhythm
d) regular
2. Cervix: 4) Vaginal exam performed by RN
a) Effacement 2)
a) 80 % effaced 5) Assisted pt. to lie on left side to increase
b) Dilatation b) 8 cm dilated comfort level.
complete dilatation at
3. Descent/Station: 11:14
3) Engaged @ 2 station 6) Changed chuck and cleaned perineal area.
@ 3 station in vertex
4. Bloody Show:
position @ 1045 7) Massaged pt. shoulders and back. 3000 ccs
RL has infused in order to maintain pt.’s
4) No increase in bloody hydration.
5. Amniotic Membranes: show but still draining
mucus and clear liquid.
8) Monitor for pain. States she only feels a
5) Ruptured
little pressure in perineal area but no c/o pain
6) 120/ 70- BP
6. Vital Signs: 75 bpm –
18 respirations 9) Pt. has no c/o pain
98.3 F axillary 10) Pt. assisted to get into lithotomy position.
7) 150 and regular 11) Encouraged pt. to push while CNM does
7. Fetal Heart Rate:
perineal massage.
Assessed pt. contraction
and pain level. States she is
8. Pain/Comfort Measures: feeling pressure but no 12) Encouraged to breathe deep and push
pain.
Noted baby’s head 13) Encouraged pt. to rest between
crowning contractions
9. Client Behaviors & General

SAFE TIME FRAMES:
ASSESSMENT CRITERIA
Appearance:
10.Family Support Measures:
STAGE I: TRANSITIONAL PHASE (Cervical Effacement/Dilatation/Descent)
SAFE TIME FRAMES: 1) Primigravida
ASSESSMENT CRITERIA
1. Contractions:
a) Frequency
b) Intensity
c) Duration
d) Rhythm
2. Cervix:
a) Effacement
b) Dilatation
3. Descent/Station:
4. Bloody Show:
5. Amniotic Membranes:
6. Vital Signs:
7. Fetal Heart Rate:
1) Primigravida
ASSESSMENT DATA
CNM assesses descent of
baby. Continues to push
anterior cervix up to
facilitate descent
ASSESSMENT DATA
Assessed for descent of
placenta
Assessed uterine fundus
Assessed bleeding. Noted to
have moderate amt. OF
DARK RED DRAINAGE.
Intrapartal Assessment Page 4
2) Multigravida.
.
NURSING INTERVENTION
Holding pt.’s legs with knees flexed to chest.
Pt. pushed 4 times and delivered baby @
11:16 with no difficulty. Cord clamped and
cut by CNM.
Noted gush of bloody liquid along with
expulsion of fetus,
Pt. cousin at bedside
2) Multigravida
NURSING INTERVENTIONS
Placenta delivered @ 1120 with no
complications.
Added 20 mu of Pitocin to 1000 CC bag of RL.
Fundus firm at umbilicus
Fundal massage performed.
Cleaned pt. perineal area and changed bed and
applied perineal pad.
Offered ice chips.
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SAFE TIME FRAMES: 1) Primigravida 2) Multigravida

ASSESSMENT CRITERIA ASSESSMENT DATA NURSING INTERVENTIONS

8. Pain/Comfort Measures:

9. Client Behaviors & General

Appearance:

10.Family Support Measures:

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STAGE II: BEGINS WITH COMPLETE CERVICAL DILATATION AND ENDS WITH BIRTH
SAFE TIME FRAMES: 1) Primigravida 2) Multigravida

ASSESSMENT CRITERIA ASSESSMENT DATA NURSING INTERVENTION

1. Contractions:
a) Frequency

b) Intensity

c) Duration

d) Rhythm

2. Descent/Station:

3. Bloody Show:

4. Vital Signs:

5. Fetal Heart Rate:

6. Episiotomy:

7. Pain/Comfort Measures:

8. Client Behaviors & General

Appearance:

9. Family Support Measures: Foley cath discontinued with 600 ccs clear yellow
urine in bag.

11.Immediate Care of the

Neonate:
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STAGE III: PLACENTAL SEPARATION

SAFE TIME FRAMES: 1)Primigravida & Multigravida

ASSESSMENT CRITERIA ASSESSMENT DATA NURSING INTERVENTION

Assisted back into supine position.
1. Signs of Placenta Separation:
a) Fundus
No c/o pain
b) Umbilical Cord
Resting well with minimal amt. of bleeding
c) Bleeding
noted.
2. Placental Delivery:
a) Schultze Mechanism
DELIVERED placenta with
shiny side up. Placenta
b) Duncan Mechanism completely expelled with
membrane around it.

3. Vital Signs: 136/84- BP

80- pulse
18 respirations
97.8 F
4. Medications Given:

5. Appearance/Behavior:
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STAGE IV: IMMEDIATE RECOVERY PAST DELIVERY

SAFE TIME FRAMES: 1)Primigravida & Multigravida

ASSESSMENT CRITERIA ASSESSMENT DATA NURSING INTERVENTION

1. Vital Signs: . Fundus firm at umbilicus

2. Fundus:

Minimal lochia rubra noted

3. Lochia: on pad

4. Bladder:
Bladder soft and non-
distended
5.
Episiotomy/perineum/rectum:
No tearing noted to
perineum

6. Medications Given:

7. Appearance/Behavior:
Pt. comfortable lying in bed.

8. Measures to Promote
Baby wrapped and laid in
Attachment/Bonding:
mama’s.

9. Pain:
No c/o pain