7. Assessment of maternal and neonatal vital signs
Frequency of observations61
Role and responsibilities of the midwife64
Having read this chapter the reader should be able to:
• describe the different components of the Glasgow Coma Scale (GCS)
• discuss how the midwife can complete the GCS
• identify the other observations that should be undertaken in conjunction with the GCS to gain a thorough neurological assessment.
Neurological assessment is undertaken on any woman when there are concerns about actual or possible alterations in her levels of consciousness (e.g. postseizure, magnesium toxicity, meningitis, head injury). A complete neurological assessment encompasses the level of consciousness, pupillary reaction, motor (including reflexes), sensory and cerebellar function and vital signs. This is the remit of the doctor with neurological experience and is completed initially and then as needed to determine the woman’s condition. The midwife’s involvement is to undertake a reduced assessment of level of consciousness, motor signs (limb movement), pupillary assessment and vital signs: respiration, heart rate, blood pressure, temperature and oxygen saturation. This chapter focuses on the principles of neurological assessment and the midwife’s role in relation to undertaking this assessment.
Frequency of observations
The midwife must be able to complete a neurological assessment competently because it provides invaluable information regarding the woman’s condition. The observations recorded should reflect the condition of the woman, and Cree (2003) recommends this should be carried out every 30 minutes until her condition has stabilized or the GCS score is 15 to enable any changes in condition to be identified early. However, the National Institute for Health and Clinical Excellence (NICE 2007) recommends that the observations should be completed every 30 minutes until the GCS is 15, when they can be recorded hourly for 4 hours, then every 2 hours, reverting to 30-minute assessments if the condition deteriorates.
Glasgow Coma Scale
The GCS was developed in 1974 and revised in 1979 to provide a quick and objective assessment of eye opening, verbal response and motor ability enabling the level of consciousness to be monitored effectively and is recognised as the ‘gold standard’ assessment tool (Palmer & Knight 2006). Each of these three categories has four to six different responses and each response is scored. The three scores are totalled to score between 15 (fully conscious) and 3 (no response) to provide a rapid assessment of the woman’s condition and response to treatment. The score should be recorded as a fraction using 15 as the denominator (e.g. 10/15).
Eye opening is the first GCS measurement of consciousness as without this cognition does not occur; however, it does not indicate the neurological system is intact (Iankova 2006).
The midwife should look at the woman to see if her eyes are opening spontaneously (score 4).
If the eyes remain closed, the midwife should speak to the woman, which should provoke the eyes to open (score 3).
If the eyes continue to remain closed, the midwife will need to use painful peripheral stimuli, such as using a pen to apply pressure against the lateral outer aspect of the second or third fingers, using the alternate finger for the next evaluation (Iankova, 2006 and Waterhouse, 2005) (score 2). Painful stimulation should be applied slowly up to a maximum of 10 seconds and should be stopped if no response has been elicited after 30 seconds. Central stimulation might elicit a response but can cause the woman to grimace whilst keeping her eyes closed, and so is not generally used unless the midwife has been appropriately trained. Jevon (2008) recommends squeezing the trapezium muscle using a thumb and two fingers, although this is difficult on large or obese women, or applying pressure to the suborbital ridge (but not if there is suspected or confirmed facial fracture or glaucoma; Palmer & Knight (2006)). The latter might cause bradycardia. Sternal rubs are used with caution because they can cause bruising. It is important to use the same stimulus on each assessment. If the eyes remain closed, a score of 1 is given. Painful stimuli should be stopped after 30 seconds if no response is achieved.
If damage has been sustained to the eyes, resulting in swelling, it is unlikely the eyes will open easily, rendering this unreliable until the swelling subsides; this should be recorded as ‘C’ (Jevon 2008).
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