Download labor and delivery observation

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LABOR AND DELIVERY OBSERVATION
DIRECTIONS:
Fill out the following information on your assigned patients in labor and delivery.
You may use your assessment where possible and assessments of your nurse
preceptor where necessary. You should make an entry at least every 30
minutes. (During the fourth stage of labor, record in columns 1,6,7,9, 10 & 11.
Under 11, include status of fundus, amount of lochia and urinary output).
Patient’s Initials
Gravida
Para
DATE
TIME
Admitted to L&D
Labor Started
Membranes
Ruptured
OBSERVATIONS OF LABOR
(1)
Time
(2)
Di/Effect
(3)
Station
(4)
Freq./Dur
(5)
FHR
(6)
T-RR/BP
(7)
Appearance
Of Perineum
(8)
Status of
Membranes
(9)
Affect of
Mother
Behavioral
(10)
Medication
(11)
Other
Comments
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QUESTIONS FOR EVALUATING LABOR AND DELIVERY OBSERVATIONS
1.
2.
Assessments of stages
a.
When did mother complete the first stage of labor?
b.
When was second stage completed?
c.
When was the third stage completed?
d.
What factors influenced the length of each stage?
What was the relationship between maternal affect and stage4?
a.
When in latent labor.
b.
When in active labor.
c.
When in transition.
d.
When in second stage.
e.
When in third stage.
3.
How did the perineal appearance change with the progress of labor?
4.
Were there significant changes in the FHT and maternal vita during
labor? If so, why?
5.
What changes occurred in the interval and duration of contractions as labor
progressed? (That is, what relationship did you see bet dilation and effacement
and the duration and interval of con
6.
What is the relationship between station and progress of lab?
7.
What kind of support was given as labor progressed, including breathing and
relaxation?  from nurse  from significant others  any medications if yes, what
types?
8.
How were the needs for fluid and electrolyte balance met dun
9.
Were there any physiological or psychological concerns for tL during labor? If so,
what? Were there data on the prenatal related to these concerns?
10.
How did the mother (significant other) respond to birth?
11.
During the fourth stage of labor what noticeable physiological changes were noted
in: (a) vital signs, (b) in position of uterus and status of bladder, (c) in voiding, (d) in
affect?