Assessment of maternal and neonatal vital signs
Neurological assessment
Learning outcomes
Having read this chapter, the reader should be able to:
Neurological assessment may be undertaken when there are concerns about actual or possible alterations in a woman’s level of consciousness (e.g. post-seizure, magnesium toxicity, meningitis, head injury). Initially a doctor with neurological experience will complete the neurological assessment evaluating level of consciousness, pupillary reaction, motor (including reflexes), sensory and cerebellar function and vital signs. A reduced assessment of level of consciousness, motor signs (limb movement), pupillary assessment in conjunction with vital signs – respiration, heart rate, blood pressure, temperature and oxygen saturation – can be undertaken by the midwife. The midwife must be appropriately trained to enable her to complete a neurological assessment competently and safely, as it provides invaluable information regarding the woman’s condition. The Modified Early Obstetric Warning Scoring (MEOWS) chart may contain some of the components of neurological assessment, e.g. alertness, response to stimulation (p. 66) This chapter focuses on the principles of neurological assessment and the midwife’s role in relation to undertaking this assessment.
Frequency of observations
NICE (2014) recommend that neurological observations should be completed every 30 minutes until the GCS is 15, when they can then 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 accepted 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. NICE (2014) state that a GCS >12 indicates a normal or minimally impaired level of consciousness. The score should be recorded as a fraction using 15 as the denominator (e.g. 10/15). NICE (2014) recommend that information about the three separate GCS responses should also be recorded, e.g. a score of 12/15 based on scores of 3 on eye opening, 4 on verbal response, and 5 on motor ability should be recorded as E3, V4, M5.
Eye opening
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). Okamura (2014) states it is assessing the integrity of the reticular activating system found in the brainstem. It cannot be used if there has been damage to the eyes resulting in swelling, as it is unlikely the eyes will open easily, rendering this aspect of the assessment unreliable until the swelling subsides. Jevon (2008) recommends recording this as ‘C’.
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). Waterhouse (2009) suggests a greater response is achieved by asking the woman if she ‘wants a cup of tea’ rather than saying her name.
If the eyes continue to remain closed, a painful peripheral stimulus is used – this may be a gentle shake but if no response a deeper stimulus is needed. Pressure is applied using a pen positioned just below the lateral outer aspect of the second or third interphalangeal joint for 10–15 seconds (Iankova 2006, Okamura 2014, Waterhouse 2009) (score 2). Painful stimulation should be applied slowly up to a maximum of 15 seconds. Pressure should not be applied to the nail bed because of the risk of bruising (Edmunds et al 2011).
If there is no response using a painful peripheral stimulus, a central painful stimulus is used. Central stimulation involves the application of a noxious painful stimulus to the core of the nervous system via the cranial nerves to elicit a complete motor response (Waterhouse 2009). However, the woman may grimace while keeping her eyes closed, and so it is not generally used unless the midwife has been appropriately trained. It is important to use the same stimulus on each assessment. A score of 1 is given if the eyes remain closed.
Jevon (2008) recommends squeezing the trapezium muscle using a thumb and two fingers and Edmunds et al (2011) advise twisting 3–5 cm of muscle from where the neck and shoulders meet for up to 30 seconds to stimulate the spinal accessory nerve (XI), although this is difficult on large or obese women. Waterhouse (2009) considers this to be the safer technique for inexperienced staff. Alternatively the supraorbital nerve, part of the trigeminal nerve (V), can be stimulated by applying pressure to the supraorbital ridge provided there is no suspected or confirmed facial fracture or glaucoma (Palmer & Knight 2006) but bradycardia may occur. This is achieved by placing the thumb into the indentation below the eyebrow, close to the nose, and applying gradual pressure for up to 30 seconds (Okamura 2014). Sternal rubs are used with caution because they can cause bruising and the flat of the hand should be used, not the knuckles. It should not be used for repeated assessments (Edmunds et al 2011).
Waterhouse (2009) recommends central painful stimulus, rather than peripheral pain stimulus, is used as it can result in both an eye opening response and assess motor ability. The type and site of the stimulus used should be documented.
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