DATE 23/12/08

NURSING DIAGNOSIS High risk for haemorrhage related to maternal soft tissue injury secondary to delivery manouvres.

GOAL

The patient ill not !leed intrapartumly" postpartumly and throughout hospitali#ation. %nstruct the patient not to !ear do n unless instructed to do so hen the cervi& is 10cm dilated.

NURSING INTERVENTIONS $sta!lish and maintain a good mid ife patient relationship

SCIENTIFIC RATIONALE The patient is likely to follo instructions from the mid ife she has trust and confidence in. To avoid soft !ody parts from slipping through a cervi& that is not fully dilated and resulting in a stuck head that ill necessitate aggressive manouvres hich can cause tears. To avoid e&tending the arms and the head that may necessitate certain aggressive manouvres that can potentiate perineal tears.

EVALUATION (heck the perineum for tears and suture them accordingly (heck the perineal pad every 30 minutes for evidence of active !leeding. (heck the vital signs" pulse rate" respirations" !lood pressure and temperature ) hourly.

'uring spontaneous !reech delivery leave the !reech alone until the !ody is !orn.

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Have the oman stop pushing hen the !ody is !orn up to um!ilicus and pull do n the loop of cord.

To prevent tension on the um!ilical cord hich may lead to early separation of the placenta hence severe hemorrhage.

*eel for the el!o s on the chest.

3!sence of el!o s on the chest ill indicate e&tended arms thus indicating 4ovsett manouvre to prevent perineal tears.

+se ,urn-s .arshall manouvre and .auriceau/ 0mellie/1eit manouvre to deliver a fle&ed and an e&tended head respectively. 2uard the perineum ith the left hand during delivery of the head

These manouvres ill manage these complications ith minimal or little perineal tears resulting. This ill prevent the head from emerging too 5uickly hich can cause perineal tears.

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'o active management of third stage i.e. provision of pitocin and controlled cord traction (heck the uterus if contracted after third stage and ru! up a contraction if not. 0uture if vaginal or perineal tear have !een sustained 6!serve for vital signs thus temperature" !lood pressure" pulse rate and signs of shock like cold clammy skin

To avoid postpartum hemorrhage

To avoid !leeding and for early interventions

To arrest !leeding To avoid missing insidious hemorrhage

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DATE 23/12/08

NURSING DIAGNOSIS 3ltered comfort pain related to uterine contractions and malpresentations as evidenced !y patient-s o n ver!ali#ation and strained facial e&pressions.

GOAL (lient ill ver!ali#e minimal levels of pain throughout the first stage of la!our.

NURSING INTERVENTIONS .assage the !ack

SCIENTIFIC RATIONALE ,ack massage stimulates the parasympathetic nervous system to send messages to the !rain therefore reducing the sympathetic transmission of pain to the pain centers in the !rain. 8armth has a soothing effect there!y reducing pain 7ethidine directly !locks pain receptors in the !rain thus reduces pain %n order to provide a diversional therapy this ill distract her from the pain. This provides some form of rela&ation therefore muscle tension is released.

EVALUATION 3ssess patient-s pain perception after 30 minutes of nursing interventions

7rovide a arm compress or a arm sho er 2ive pethidine 100mg intramuscularly (hat ith the patient if feasi!le $ncourage slo rhythmic deep !reathing

$ncourage fre5uent To avoid continuous muscle change of tension. positions

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DATE 23/12/08

NURSING DIAGNOSIS High risk for altered fluid !alance and nutrition related to hyperventilation" 0lo ed digestive function and emptying time of the stomach and reduced food intake.

GOAL

NURSING INTERVENTIONS (lient ill 7rovide client ith maintain ade5uate light porridge in fluids and nutrition latent phase of throughout la!our la!our if not and delivery contra indicated. 2ive the client sips of ater if not contra indicated. (ommence 1 litre of an intravenous infusion of 9: 'e&trose to run for 3 hours 0mear the lips ith 1aseline jelly

SCIENTIFIC RATIONALE 4ight porridge gets easily digested and provides nutrients to the motherTo ensure ade5uate hydration status. 'e&trose ill provide fluids and some energy to the mother To retain moisture thus preventing insensi!le loss of ater.

EVALUATION (heck the lips and skin for hydration status hourly.

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DATE 23/12/08

NURSING DIAGNOSIS High risk for infection related to possi!le increased num!er of vaginal e&aminations during la!our and early rupture of mem!ranes.

GOAL The client ill !e free from infection during la!our and delivery and throughout hospital stay

NURSING INTERVENTIONS .aintain aseptic techni5ue hen performing all procedures. .inimi#e invasive procedures and avoid unnecessary ones.

SCIENTIFIC RATIONALE %n order to prevent introducing infection into the reproductive truct. To reduce risk of introducing infections in client.

EVALUATION .onitor !ody temperature ; hourly

7rovide clean linen and clean environment.

'irty linen is a media for gro th of disease causing micro!es.

(lean the perineum hen it gets dirty 7rovide a sterile pad follo ing rupture of

This ill reduce micro/organisms that can cause infection. This ill control and prevent entry of micro/

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mem!ranes.

organisms that can cause infection. This ill cover for aero!ic and anaero!ic micro organisms hich can cause infection

3dminister anti!iotics to client if mem!ranes have ruptured for more than 12 hours

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DATE 23/12/08

NURSING DIAGNOSIS %neffective individual coping an&iety related to la!ouring in an unfamiliar environment" kno ledge deficit on la!our and delivery process and outcome of !reech presentation

GOAL (lient ill demonstrate and indicate minimal levels of an&iety throughout first stage of la!our

NURSING INTERVENTIONS 6rient client to la!our ard. (reate a arm and receptive environment for the client

SCIENTIFIC RATIONALE To make her familiar ith the ard. This ill free the client and make her feel comforta!le to ver!ali#e her concerns. This ill provide her ith proper understanding hence reducing an&iety

EVALUATION 6!serve client-s stress levels

$&plain to the client a!out !reech presentation and the course of la!our and delivery in simple terms. 7rovide encouragement and support. $&plain e&pectations during la!our in terms of position

0upport during la!our leads to favora!le outcomes This ill promote co/operation during delivery

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and !earing do n techni5ues $ncourage her to ask 5uestions and ver!ali#e concerns. This ena!les the mid ife to have insight of client-s misconceptions hich if corrected can lead to relief of an&iety.

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DATE 23/12/08

NURSING DIAGNOSIS High risk for fetal hypo&ia related to compression of the placenta during uterine contractions" compression of the cord during delivery of the trunk and inade5uate food in take !y the mother

GOAL The fetus ill have ade5uate o&ygen throughout first stage of la!our

NURSING INTERVENTIONS Teach the client rela&ation techni5ue e.g. rhythmic !reathing $ncourage the client to lie in left lateral position

SCIENTIFIC RATIONALE This ill make the client rela& and maintain ade5uate supply of o&ygen to the fetus This position ill prevent compression of the inferior vena cava and aorta thus promoting ade5uate supply of o&ygen to the fetus and uterus. This prevents keto/acidosis hich impede o&ygenation to the fetus This ill prevent compression of the cord hence preventing fetal hypo&ia

EVALUATION .onitor fetal heart rate half hourly. 8hen mem!ranes rupture check colour of li5uor hourly" if intact" check 3/; hourly.

(ontinue giving the client food hile in la!our e.g. light porridge 7ull do n the loop of the um!ilical cord after delivery of the !ody up to um!ilicus.

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