Labor & Delivery Assessment Worksheet
STUDENT_________________
HEALTH CARE OF WOMEN Date______________________
Labor And Delivery Assessment Worksheet
Patient initials: Age: Marital Status: DOB:
Admission Date and Time: Vital Signs: BP T P R
Gravida Term Preterm Abortions Living Children
LMP EDC GA by dates GA by sonogram
Received Prenatal Care? Yes No Where?
GA at 1st prenatal visit GA when FHTs first heard
Blood Type: Hgb/Hct: Urinalysis:
Identified risk factors:
Contractions: None Begun Date/Time:
Frequency Duration Intensity
Membranes: Intact Ruptured Date/Time:
Nitrazine: Positive Negative N/A
Fluid color: Clear Meconium Vaginal …show more content…
5 min. 10 min.
Heart rate
Muscle tone
Reflex Irritability
Respiratory effort …show more content…
It is only used to monitor the baby's heart rate during labor, usually if external monitoring is not being reliable (but sometimes if the caregiver prefers internal to external monitoring.
Advantages of internal monitoring: a more accurate fetal heart rate measurement, allows for early detection of common labor complications
Disadvantages: Can introduce bacteria into the uterus, creating a risk of infection for mom and baby; restricts movement of mom, leading to more pain.
EXTERNAL / INDIRECT: Tocodynamometer - An instrument for measuring the force of uterine contractions. It consists of a pressure transducer that is applied to the fundus of the uterus by means of a belt, which is connected to a machine that records the duration of the contractions and the interval between them on graph paper. The relative intensity of the contractions is also indicated but cannot be quantified.
Ultrasound - uses reflected sound waves instead of x-rays to create pictures of the internal organs. This makes it a safer alternative for internal images during pregnancy.
Advantages – Non-invasive, does not require rupture of membranes.
Disadvantages – none
HEALTH CARE OF WOMEN Date______________________
Labor And Delivery Assessment Worksheet
Patient initials: Age: Marital Status: DOB:
Admission Date and Time: Vital Signs: BP T P R
Gravida Term Preterm Abortions Living Children
LMP EDC GA by dates GA by sonogram
Received Prenatal Care? Yes No Where?
GA at 1st prenatal visit GA when FHTs first heard
Blood Type: Hgb/Hct: Urinalysis:
Identified risk factors:
Contractions: None Begun Date/Time:
Frequency Duration Intensity
Membranes: Intact Ruptured Date/Time:
Nitrazine: Positive Negative N/A
Fluid color: Clear Meconium Vaginal …show more content…
5 min. 10 min.
Heart rate
Muscle tone
Reflex Irritability
Respiratory effort …show more content…
It is only used to monitor the baby's heart rate during labor, usually if external monitoring is not being reliable (but sometimes if the caregiver prefers internal to external monitoring.
Advantages of internal monitoring: a more accurate fetal heart rate measurement, allows for early detection of common labor complications
Disadvantages: Can introduce bacteria into the uterus, creating a risk of infection for mom and baby; restricts movement of mom, leading to more pain.
EXTERNAL / INDIRECT: Tocodynamometer - An instrument for measuring the force of uterine contractions. It consists of a pressure transducer that is applied to the fundus of the uterus by means of a belt, which is connected to a machine that records the duration of the contractions and the interval between them on graph paper. The relative intensity of the contractions is also indicated but cannot be quantified.
Ultrasound - uses reflected sound waves instead of x-rays to create pictures of the internal organs. This makes it a safer alternative for internal images during pregnancy.
Advantages – Non-invasive, does not require rupture of membranes.
Disadvantages – none