Admission Assessment of the Laboring Woman

Admission Assessment of the Laboring Woman

Diane J. Angelini

E. Jean Martin

Donna J. Ruth

Identifying Critical Information

Certain information is needed immediately to evaluate the following:

  • The extent of the woman’s labor

  • Her general physical condition

  • Her risk status

  • Her preparation for labor and delivery

This assessment must be carried out quickly to determine how active the labor is and to become alert to women with a history of rapid deliveries or those with problems denoting risk.

Questions Information Needed
1. What made you come to the hospital? 1. Presenting complaint
2. When were you told the baby was due? 2. Expected date of delivery/confinement (EDD/EDC) and how it was determined:

  • by dates
  • by size
  • by ultrasound and during which trimester the ultrasound was performed

Dating criteria by ACOG: Ultrasound confirmation of gestational age should be in agreement with menstrual dates within 4 days when performed at 6 to 9.6 weeks; within 7 days at 10 to 13.6 weeks or within 10 days when performed at 14 to 20 weeks. Dating after 20 weeks by ultrasound is not completely accurate.1
3. How many babies have you had? 3. Projection about possible rapid labor due to multiparity
4. When did your labor begin? How far apart are the contractions? Have they changed in intensity? Have you had any bleeding? 4. Stage of labor she is in:

  • Frequency, duration, and intensity of contractions
  • Amount and character of bloody show
  • Identification of abnormal bleeding versus bloody show
5. Has the bag of water (membranes) broken, and when did it occur? What color was the fluid? 5. Whether or not membranes have ruptured

  • Risk of chorioamnionitis owing to prolonged rupture of membranes
  • Presence or absence of meconium-stained or bloody amniotic fluid
6. How has your pregnancy been? Did you have any problems that required special treatment? Have you had any bleeding? 6. Any abnormalities in the pregnancy—specifically ask about problems with blood pressure (BP), bleeding, or infections
7. When did you last have anything to eat or drink? What were these foods? 7. Extent of gastric fullness
8. Are you allergic to any foods or drugs that you know of? 8. Any known allergies to drugs
9. Who has come with you? Will they be staying with you during labor? 9. Presence of a support system
10. Have you had any preparation for this labor and delivery? 10. Knowledge level regarding the birth experience
11. Is there anything special about your pregnancy that I should know? 11. To elicit information that could affect her labor/delivery or the newborn
  Opportunity for woman to share specific concerns regarding her care

Guidelines for History Taking

  • Maintain eye contact.

  • Introduce yourself and confirm the name by which the woman wishes to be called.

  • Inform the woman that you need to ask several questions and that you will stop whenever a contraction begins.

  • Ask open-ended questions when possible. For example, “Can you tell me about any problems you have had during this pregnancy?” instead of “Have you had an infection (or problem) during this pregnancy?” and “What preparation have you had for your labor and delivery?” instead of “Have you attended childbirth preparation classes?”

Identifying the High-Risk Mother and Fetus

Mothers with high-risk pregnancies tend to have high-risk infants. These patients need to be identified as early as possible on admittance to the labor unit. Women who begin pregnancy as a low-risk patient may develop complications that make them high risk during the labor and delivery process. Assessment on admission and throughout the labor process will help to identify these women in a timely manner.

Taking a good history and reviewing the prenatal record of the woman when she is admitted to the labor unit is necessary for identifying the high-risk intrapartal patient. Risk status may have changed in the period between the last prenatal visit and admission for delivery.

Risk Factors for Laboring Women

Extremes of age  
Fifth or more pregnancy  
Height 60 in or less  
Little or no weight gain during pregnancy  
Cigarette smoking  
Rh incompatibility or ABO incompatibility problems  
Previous premature deliveries  
Previous birth to a large infant (>4,000 g/9 lb—macrosomia)
Previous perinatal loss  
Less than a high school education or in the poverty-level income group  
Single marital status  
Unplanned pregnancy  
Little or no antenatal care  
History of a congenital anomaly or medical disorder, such as anemia, diabetes, renal disease, cardiac problems, malignant tumors, or psychiatric disorders  
Symptoms of oral (type 1) or genital (type 2) herpes simplex virus (HSV) or a current positive herpes culture; current symptoms, especially significant if the genital herpes infection present is the woman’s first infection (primary infection) experienced during pregnancy NOTE: Ulcerative genital complaints are symptomatic of many kinds of infections (e.g., chancroid, secondary infected syphilis, contact dermatitis).
Lesions appear as blister-like vesicles, which progress to a crusted or ulcer-type appearance. HSV of either type 1 or 2 can be shed at the cervix in symptomatic and asymptomatic women. Women with prior HSV type 2 infections who are asymptomatic have a low risk of shedding the virus during delivery Cesarean delivery is recommended when typical herpes lesions are present at labor, regardless of time since membrane rupture3
Risk factors for HSV include: (a) previous infant with invasive GBS disease; (b) GBS bacterium with this pregnancy; (c) delivery at less than 37 weeks’ gestation; (d) unknown GBS status with amniotic membrane rupture >18 hours or intrapartum temperature ≥100.4°F
Vertical transmission of GBS during labor or delivery may result in newborn sepsis, pneumonia, or less frequently meningitis. All pregnant women should be screened at 35 to 37 weeks with a single culture swab from both the lower vagina and rectum4,5  
Partner currently has or has a history of herpes  
Active herpes in a partner can expose the sexually active mother and can unwittingly infect a newborn after birth. Parents need to be educated on the possible risk that HSV imposes on the newborn. Sources of risk include children, grandparents, and so on, who have oral lesions as well. Contact with the newborn should be avoided by anyone with a current infection  
At risk for hepatitis B carrier status and no documentation of a negative screen  
At risk for HIV infection  
History of previous obstetric complications, such as preeclampsia, multiple pregnancy, or hydramnios  
Abnormal presentation (breech presentation or transverse lie)  
Fetus has failed to grow normally or fetus does not reach the expected size for dates  

The following factors are associated with the development of complications for either the mother or the baby both during and after labor and delivery.

Factors Identified From the Mother’s History

  • Diabetes

  • Preeclampsia or eclampsia

  • Rh sensitization

  • Sickle cell disease

  • Heart disease

  • Sexually transmitted infections

  • Chronic hypertension

  • Previous perinatal loss

  • Anemia

  • Renal disease

  • Carrier state for blood-borne infectious disease (e.g., hepatitis B, syphilis, or HIV)

  • Group B streptococcus (GBS) carrier status

Factors That Develop During Pregnancy

  • Preeclampsia

  • Gestational hypertension

  • Postterm pregnancy (more than 42 weeks’ gestation)

  • Hydramnios or oligohydramnios

  • Third trimester bleeding of undetermined origin

  • Abruptio placentae or placenta previa

Factors Related to the Fetus

  • Irregularity in fetal heart rate (FHR) or nonreassuring FHR patterns

  • Intrauterine growth restriction

  • Prematurity

  • Malpresentation

  • Significant increase or decrease in current fetal activity

  • Meconium-stained amniotic fluid

Factors Developing During Early Labor

  • Chorioamnionitis

  • Premature rupture of membranes (PROM) at term

  • Fresh meconium-stained fluid

  • Abnormal fetal heart tones or nonreassuring FHR patterns

  • Suspected cephalopelvic disproportion

Determining True Labor

The uterus undergoes intermittent contractions once pregnancy is established. These contractions are called Braxton–Hicks contractions, and they are often associated with false labor. After the 28th week of pregnancy, these contractions become definite and more noticeable by the woman.

As the 37th week of pregnancy approaches, contractions can be strong and are sometimes perceived by the expectant mother as a sign of true labor. Braxton–Hicks contractions usually stop or become highly irregular with a change of activity.

True Labor False Labor
Show—is often present. Show is blood-tinged mucus released from the cervical canal as labor nears or begins. It is pink, red, or brownish. Show—is absent or can be related to intercourse or to a recent vaginal examination. It is brownish when the bleeding occurs hours before discovery.
NOTE: Bloody show without contractions indicates that the body is preparing for labor but labor is not present without regular contractions and cervical change.  
Contractions—tend to occur at regular intervals. They start at the back and sweep around to the abdomen, increasing in intensity and duration over several hours. They often intensify with walking. Contractions—are irregular. They may be felt only in the back or in the lower abdomen. They do not intensify with walking and gradually diminish over several hours.
NOTE: Regular and intensifying contractions are the single most important indication that labor might have begun.  
Fetal movement—no significant change is noted. Fetal movement—can increase for a short time or remain the same.
Cervix—becomes effaced and dilated. Cervix—no change is noted or very small changes in thinning out (effacement) occur. Contractions help to bring about effacement.
NOTE: Progressive cervical dilatation is the hallmark of progress in labor.  
Walking—increases the intensity of contractions. Walking—does not change the intensity of contractions.
Sedation—does not stop true labor. Sedation—tends to stop false labor or prodromal labor.
In addition, for some women:  
Bowel status—can have loose stools 1 or 2 days before the onset of labor. Bowel status—is usually unchanged.
Nesting—women tend to experience a flurry of activity in housecleaning 1 or 2 days before the onset of labor. Nesting—none is present.

Evaluating the Status of Membranes

While developing inside the uterus, the fetus lives in a sac. The sac has two layers: the inner layer, called the amnion, and the outer covering, called the chorion. This sac is filled with fluid that is made up of water, various chemicals (e.g., salts), and particles that come from the fetus itself (e.g., body cells and hair).

By the end of pregnancy, the uterus contains approximately 1 L of amniotic fluid. The fluid is clear or straw colored and has a characteristic (not foul) odor. When tested for its acid–base content, it ranges from neutral to slightly alkaline. A close relationship exists between the status of the fluid and the health of the fetus. By studying various components of amniotic fluid, one can learn much about the gender, health, and maturity of the baby.

The fetus derives many benefits from amniotic fluid, which does the following:

  • Protects the fetus from a direct blow. Pressure from a blow spreads in all directions within the fluid-filled sac, so the fetus does not receive the full impact of the blow.

  • Provides a fluid environment in which the fetus moves. This fluid continually changes in amount and consistency, promoting the growth and development of the fetus.

  • Prevents loss of heat and permits the fetus to maintain a constant body temperature.

  • Provides a source of oral intake. The fetus swallows amniotic fluid from approximately the fourth month until delivery.

  • Acts as a collection system for the waste products of the fetus. The fetus urinates into the amniotic fluid from the fourth month until delivery.

A. Premature Rupture of Membranes (PROM) Before Labor Begins With a Term Fetus at 37 Completed Weeks or More Gestational Age

Membranes (“bag of waters”) can rupture before labor begins. The break in the membranes can be complete, with a large gushing of fluid from the birth canal, or a small tear with a slow leak.

B. Preterm Premature Rupture of Membranes (PPROM) Before Labor Begins With a Preterm Fetus Less than 37 Weeks’ gestation

When rupture occurs before the fetus has reached the 37th completed week of gestation, perinatal morbidity and mortality increase. These women should be monitored for signs and symptoms of infection.

C. Meconium-Stained Amniotic Fluid

Fetal stool is referred to as meconium. It is largely made up of water, but also contains proteins, cholesterol, lipids, vernix, and other substances. Large concentrations of bile pigments give meconium its green color. Meconium present for more than 24 hours begins to turn yellow-green.

Almost all fetuses and newborn infants who pass meconium are at term or postterm gestation. From 20 to 34 weeks’ gestation, fetal passage of meconium remains infrequent.7 Although 12% to 22% of labors are complicated by meconium, only a few are linked to infant mortality.2

The significance of meconium-stained amniotic fluid as a predictor of fetal compromise may depend on the following:

  • Concentration and type of meconium (e.g., thick or thin, color, amount)

  • Gestational age

  • Stage of labor when the meconium is passed (often not known)

  • The presence of other fetal compromise markers such as FHR abnormalities or oligohydramnios

Birth of a depressed infant occurs in 20% to 33% of infants born through meconium-stained amniotic fluid. It is likely caused by pathologic intrauterine processes, primarily chronic asphyxia and infection.7

Meconium aspiration syndrome (MAS) is thought to be caused by an initial hypoxic event resulting in the release of meconium into the amniotic fluid. The normal fetal response to hypoxemia is to gasp, and thus in this instance, the meconium is aspirated and can be seen below the vocal cords on examination.

NOTE: MAS is significantly associated with fetal acidemia at birth.8

Related Facts

Meconium is rarely passed before the 34th gestational week.

Clinical studies indicate an association between the passage of meconium and high-risk clinical situations, including the following:

  • Acute chorioamnionitis

  • PROM

  • Abruptio placentae

  • Cocaine use

  • Postterm pregnancy

Meconium alone is not an indicator of fetal hypoxia. Look at other fetal assessment parameters.

Electronic fetal monitoring maybe recommended when meconium-stained amniotic fluid is present. Meconium-stained infants should not have suctioning on the perineum. They should be handed directly to pediatrics for evaluation.

Postterm pregnancies are defined as those lasting beyond 42 weeks’ gestation. Most women are offered induction early in the 41st week.

In postterm laboring women, you should look for the following:

  • The presence of meconium-stained fluid

  • The absence of any amniotic fluid—This should alert you to the almost certain presence of meconium even though you cannot see it!

  • Placental dysfunction—Watch for late decelerations

  • Umbilical cord compression—Watch for variable decelerations

  • Macrosomia

D. Infection

Amniotic membranes and fluid can become infected, especially after 24 hours of ruptured membranes. Infection can be detected by the presence of a foul odor, fundal tenderness, and an elevated temperature in the mother of 100.4 or greater.

E. Port Wine–Colored Amniotic Fluid—AN EMERGENCY

Port wine–colored amniotic fluid is an indicator of a premature separation of the placenta from the uterine wall, called abruptio placentae or vasa previa.

Signs of Abruptio Placentae

The following signs indicate that the placenta has partially or totally separated from the uterine wall:

  • Tender abdomen

  • Hard or rigid tone to abdomen

  • Bradycardia or absence of fetal heart tones

  • External bright red bleeding or concealed bleeding, shock

Vasa previa is noted when placental vessels overlie the cervix or portions of the cervix and are covered only with membrane. These vessels are vulnerable to compression which can lead to fetal anoxia and to laceration leading to fetal exsanguination. Vasa previa is relatively uncommon, 1 in 5,200 pregnancies.9

Abruptio placentae occurs in approximately 1 in 160 to 290 deliveries,10,11 although most people consider it to be 1 in 200. Factors that may predispose a woman to developing abruptio placentae include the following:

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Jul 10, 2020 | Posted by in NURSING | Comments Off on Admission Assessment of the Laboring Woman

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