Documenting Your Arom Journey: Tips For Efficient Note-Taking

AROM, or amniotomy, is an artificial rupture of membranes performed to shorten labour by stimulating the uterine contraction pattern. It is important to document the AROM procedure and characteristics of the amniotic fluid, including its colour, clarity, odour, consistency, and amount. This information is crucial for preparing appropriate interventions during childbirth. Nurses play a vital role in this process by providing support to the practitioner, monitoring maternal and fetal responses, and documenting the relevant details.

Documenting amniotic fluid characteristics

Assessment of Amniotic Fluid Characteristics

The nurse or practitioner should assess and document the characteristics of the amniotic fluid immediately after the AROM procedure. The following characteristics should be evaluated and recorded:

• Colour: Clear amniotic fluid is considered normal. Any discolouration, such as green or muddy yellow, may indicate the presence of meconium and potential fetal distress.
• Clarity: Note the clarity of the fluid, as cloudy or purulent fluid may indicate an infection, such as chorioamnionitis.
• Odour: Amniotic fluid typically has a mild musty odour. A foul or pungent odour may be a sign of infection.
• Consistency: Any abnormalities in the consistency, such as particulate matter or thickening, should be documented.
• Volume: Assess and record the amount of fluid released. A small amount of fluid upon membrane release is expected if the fetal presenting part is well applied to the cervix.

Documentation and Monitoring

• Record the time of the AROM procedure and the characteristics of the amniotic fluid in the patient's medical record.
• Continue to monitor the amniotic fluid characteristics, especially after the rupture of the amniotic membranes, as the risk of intrauterine infection increases with the duration of membrane rupture.
• Notify the practitioner of any changes or abnormalities in the amniotic fluid characteristics, as it may indicate the need for further interventions or resuscitative measures for the newborn.
• Document any interventions or treatments provided based on the assessment of amniotic fluid characteristics.

Recording fetal heart rate

There are two ways to record fetal heart rate: external and internal. External fetal heart monitoring is typically done during prenatal visits and labour. It involves using a device such as a Doppler ultrasound or a fetoscope to listen to and record the baby's heartbeat through the mother's abdomen. The healthcare provider may use a gel on the abdomen and move the device around until they find the fetal heartbeat. For continuous monitoring, a wide elastic belt may be used to hold the device in place, and the heart rate can be displayed on a computer screen or printed on paper.

Internal fetal heart monitoring, on the other hand, involves inserting a thin wire or electrode through the cervix and attaching it to the baby's scalp. This method provides better readings as it is not affected by factors such as movement. However, it can only be performed once the amniotic sac has broken and the cervix is opened.

During labour, the healthcare provider will monitor both the mother's contractions and the baby's heart rate simultaneously. This allows them to compare the results and take appropriate actions if there are any concerns.

It is important to note that fetal heart rate monitoring is especially useful for high-risk pregnancies, such as those with underlying health conditions like diabetes or high blood pressure, or when the baby is not developing normally.

Assessing patient's vital signs

Assessing a patient's vital signs is a critical first step in any clinical evaluation. Vital signs are objective measurements of essential physiological functions, and they provide valuable insights into a patient's health status. Here is a detailed guide on assessing a patient's vital signs:

Temperature:

Temperature measurement is crucial as it reflects the body's ability to regulate heat. The normal body temperature for a healthy adult is approximately 98.6°F (37°C). However, it's important to acknowledge that body temperature can vary due to factors such as sex, recent activity, food and fluid intake, time of day, and menstrual cycle. Different methods for measuring temperature include oral, rectal, axillary (under the arm), and tympanic (in the ear). Each method has its advantages and disadvantages, with oral measurement being the most convenient and reliable.

Heart Rate/Pulse:

Heart rate, or pulse, refers to the number of heartbeats per minute. A normal heart rate for a healthy adult ranges from 60 to 100 beats per minute. It can be measured at the wrist by feeling the pulse and counting the beats for 15 seconds, then multiplying that number by 4. Heart rate can fluctuate due to various factors such as exercise, medication, anxiety, and stress.

Respiratory Rate:

Respiratory rate is the number of breaths taken per minute. A normal respiratory rate for a healthy adult is between 12 and 18 breaths per minute. It is typically measured when the person is at rest. Like other vital signs, the respiratory rate may increase due to fever, illness, or other medical conditions.

Blood Pressure:

Blood pressure reflects the force exerted by blood on the walls of blood vessels. It is measured in two numbers: systolic pressure (when the heart contracts) and diastolic pressure (when the heart relaxes). Normal blood pressure values for a healthy adult range from 90/60 mmHg to 120/80 mmHg. It is important to ensure accurate blood pressure measurement by considering factors such as recent caffeine intake, smoking, a full bladder, and proper positioning of the patient.

Additional Considerations:

It is important to note that vital signs can vary with age, sex, weight, exercise capability, and overall health. Additionally, in the context of an artificial rupture of membranes (AROM), it is crucial to assess the patient's vital signs before the procedure. This includes verifying the patient's identity, reviewing their prenatal history, and assessing contraindications to AROM.

Monitoring for complications

Fetal Heart Rate Monitoring:

• Continuously monitor the fetal heart rate via electronic fetal monitoring and communicate any findings to the provider.
• Any changes in the fetal heart rate, such as decelerations, can indicate umbilical cord issues or fetal distress.
• Notify the practitioner immediately of any adverse reactions or abnormal heart rate patterns.

Amniotic Fluid Assessment:

• Note the color, clarity, odor, consistency, and amount of amniotic fluid during and after the procedure.
• Blood-tinged, meconium-stained, or purulent fluid may indicate complications or infections.
• Monitor the amount of fluid draining and be vigilant for umbilical cord prolapse, especially after the initial flow of amniotic fluid.

Maternal Infection Monitoring:

• Assess the patient's vital signs, including temperature, periodically.
• Elevations in maternal heart and respiratory rates, uterine tenderness, and foul-smelling vaginal discharge can indicate an infection.
• Perform perineal care and change underpads to maintain patient comfort and hygiene.

Fetal Presentation and Engagement:

• Ensure that the fetal presenting part is well-applied to the cervix and that the fetal head is engaged in the pelvis before performing AROM.
• If the fetal head is not engaged, there is a risk of umbilical cord prolapse during the procedure.

Umbilical Cord Complications:

• Be vigilant for signs of umbilical cord prolapse or compression during and after AROM.
• If the cord prolapse occurs, take immediate action to manage the complication and prevent fetal distress.

Intra-amniotic Infection:

• Once the amniotic membranes rupture, the risk of intrauterine infection increases with the duration of membrane rupture.
• Administer antibiotics to patients with intrapartum risk factors, such as Group Beta Streptococcus (GBS) unknown culture results or indications of infection.

Placental Abruption:

• Monitor the patient for signs of placental abruption, such as vaginal bleeding, abdominal pain, or changes in uterine tone.
• This complication requires immediate medical attention.

It is important to closely monitor both the mother and fetus during and after AROM to identify and manage any potential complications promptly.

Noting patient's position and therapist's position

When documenting a patient's active range of motion (AROM), it is important to note the patient's position and the therapist's position to ensure accurate and detailed records. Here are 4-6 paragraphs with instructive and focused content on this topic:

Noting the Patient's Position:

The patient's position during AROM exercises will vary depending on the specific joint and muscle group being assessed. For example, when evaluating the knee, the patient may be instructed to lie down, sit, or stand. It is important to document this position accurately. The patient's starting position should be comfortable and stable, allowing for a smooth transition into the movement. For instance, if assessing the range of motion of the shoulder, the patient may start in a standing position with their arms relaxed at their sides.

Describing Movement from the Starting Position:

When noting the patient's position, it is crucial to describe the movement initiated from the starting position. This includes the direction and type of movement. For example, the therapist may instruct the patient to "lift the arm laterally to shoulder height." This description provides clear information about the expected movement. It is also essential to specify the plane of movement, such as flexion, extension, abduction, or adduction, to provide a comprehensive understanding of the patient's motion.

Therapist's Position:

The therapist's position during AROM assessment and exercises is also important to document. The therapist may need to stand or sit in a specific location relative to the patient to ensure proper observation, guidance, and assistance. For instance, when assessing shoulder abduction, the therapist might position themselves directly in front of the patient to observe the movement of the shoulder joint and provide instructions or assistance as needed.

Adjustments and Assistance:

In some cases, the therapist may need to make adjustments to their position or provide hands-on assistance during AROM exercises. This could involve gently moving the patient's limb to assess passive range of motion or providing resistance to increase the challenge. It is important to document any such adjustments or assistance provided, as it contributes to the overall understanding of the patient's condition and progress.

Patient Comfort and Safety:

Ensuring patient comfort and safety should be a priority during AROM assessments. The therapist should position themselves in a way that promotes patient comfort and facilitates clear communication. Additionally, the therapist should be prepared to adjust their position or provide assistance if the patient experiences any discomfort or difficulty during the movements. This proactive approach helps build trust and ensures a positive therapeutic experience.

Frequently asked questions