A. NURSING DIAGNOSIS
1. Health-Seeking behaviors
2. Anxiety
3. Ineffective Individual Coping
4. Pain
5. Risk for Injury
6. Risk for Ineffective airway clearance (newborn)
7. Risk for Hypoxia
B. PLANNING AND OUTCOME IDENTIFICATION
1. The woman will be property admitted to the labor and delivery unit.
2. The woman will be partner will understand normal labor process and progress.
3. The woman and the partner will implement good coaching, breathing and other …
4. The woman will receive physical, emotional, and pharmacologic support as needed.
5. The woman will experience maximum safety.
6. The woman will be prepared for the birth of her child.
7. The newborn will receive essential immediate care.
8. The newborn and parents will experience early contact.
C. IMPLEMENTATION
1. Perform admission procedures.
a. Collect urine specimen and other samples for laboratory testing as prescribed (such as hemoglobin, hematocrit, serologic tests for syphilis, and type and cross-match if indicated)
b. Perform perineal preparation and enema, if indicated.
c. Notify attending physician or midwife, and report status.
d. Obtain informed consent from the client.
2. Provided client and family teaching throughout the first and second stages.
a. Explain how activity toileting and hydration needs will be met during labor.
b. Explain equipment that will be used to monitor vital signs, labor and fetal status.
c. Explain the normal process and progress of labor and delivery to the woman and her support person.
d. Explain to the woman, that as the fetus descends in the birth canal, she will feel increased rectal pressure or the urge to push.
e. Coach the woman regarding effective pushing effort. Explain the importance of assuming a position that facilitates exclusive efforts, maintains placental perfusion and prevents or alleviates cord compression.
3.Reinforce coaching, breathing, and other relaxation measures.
4. Provide physical, emotional, and pharmacologic support as needed throughout the first and second stages.
a. Provide pleasant, comfortable, surroundings
b. Collaborative with the client and birth attendant to determine the most effective method of pain relief during each stage of the intrapartum period.
c. Provide pharmacologic support as prescribed (see Drug Chart 9-1, page 134)
d. Provide support during contractions by coaching breathing, giving back rubs and offering cool cloths.
e.Assist the client with pushing as indicated.