Performing an assessment of mother during the intranatal period—from the onset of labor until delivery—is essential for ensuring maternal and fetal well-being and guiding timely interventions.
Definition
Observation and examination of mother and fetus to determine their health status (mother and fetus) and the progress levels of labor at intervals during intranatal period.
Purposes
- To monitor the condition of labouring woman.
- To determine the condition of fetus.
- To monitor the progress of labor and any deviations from normal.
Articles
- Thermometer.
- Sphygmomanometer.
- Stethoscope.
- Wrist watch.
- Measuring tape.
- Gloves.
- Mask.
- Lubricating jelly.
- Betadine solution.
- Plastic apron.
- Partograph record blank.
- Sterile sponge holding forceps.
- Sterile bowl with cotton balls.
- Sterile perineal pad.
Procedure for assessment of mother during intranatal period
| Nursing actions | Rationale | |
| 1. | Review the patient’s prenatal record (history, care, and estimated date of delivery). | Provides basic information about pregnancy status. |
| 2. | Explain to mother the procedures and position her comfortably in bed. | Mother understands the need for various examinations and cooperation. |
| 3. | Check mother’s temperature, blood pressure and pulse. | To observe and assess the physiological status. |
| 4. | Check urine for protein, glucose, and ketone. | To detect any deviations from normal. |
| 5. | Assess fetal size, position, and presentation. | To access if the mother may have normal delivery. |
| 6. | Assess FHR. | To assess the condition of fetus and to exclude any distress signs. |
| 7. | Check for presence and grade of liquor amnii. | To assess fetal health. |
| 8. | Check the descend level of presenting part at regular intervals. | To assess the progress of labor and compare with the expected normal level. |
| 9. | Check the FHR on fetal heart monitor or at regular intervals if not on continuous monitoring. | To detect early, any change or indication of fetal distress. |
| 10. | Check the dilatation of cervix on 0-10 scale at intervals. | To assess the progress of labor. |
| 11. | Check the regularity and rhythm of uterine contractions on the monitor. | To assess the progress and normality of labor. |
| 12. | Maintain partograph (graphical record of key parameters of mother and fetus as labor progress). | Obtains maternal and fetal data during labor on a single sheet for assessment. |
| 13. | Continue to reassess the uterine contractions, FHR, and progress of labor through second stage of labor. | Helps in providing appropriate care and reassurance to mother and family. |
Red Flags to Watch For
- FHR <110 or >160 bpm
- Meconium-stained or foul-smelling amniotic fluid
- Prolonged labor or no cervical change
- Vaginal bleeding
- Severe headache or visual changes (possible preeclampsia)
Special Considerations
| Category | Consideration | Rationale |
|---|---|---|
| Infection Control | Use sterile gloves, clean perineum before vaginal exams | Prevents ascending infections, especially with ruptured membranes |
| Cultural Sensitivity | Respect modesty, involve family if appropriate | Enhances trust and cooperation |
| Emotional Support | Provide reassurance, explain procedures | Reduces anxiety and promotes positive birth experience |
| Pain Assessment | Use pain scales, offer non-pharmacologic relief | Guides timely interventions and comfort |
| Fetal Monitoring | Adjust frequency based on risk level (e.g., every 15 min in active labor) | Detects early signs of fetal distress |
| Vaginal Exams | Limit frequency, especially after ROM | Reduces infection risk |
| Hydration & Nutrition | Monitor intake/output; IV fluids if NPO | Prevents dehydration and supports uterine function |
| Positioning | Encourage upright or lateral positions | Promotes labor progress and fetal descent |
| Documentation | Use partograph and detailed notes | Ensures continuity and legal protection |
| High-Risk Conditions | Watch for signs of preeclampsia, obstructed labor, or cord prolapse | Enables rapid response and escalation of care |
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
- Annamma Jacob, Manual of Midwifery and Gynaecological Nursing, 4th Edition, 2023, Jaypee Publishers, ISBN: 978-9356961593
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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