Silliman University

COLLEGE OF NURSING

3 PRIORITY NURSING CARE PLANS DURING DELIVERY

(Second Stage of Labor)

Submitted to: Asst. Prof. Zillah R. Tobongbanua, MN, RN, RM, LPT

Prepared by: Ryan Robert V. Ventolero, S.N.

 SILLIMAN UNIVERSITY
College of Nursing
Dumaguete City
NURSING CARE PLAN

Scenario: Helen Guani, 22 years old, is pregnant with her second child. She has no partner and lives with her parents who are against her situation. In 39 weeks of
gestation as per her 18th-week ultrasound, she presented with uterine contractions coming every 4 min apart and increasing in intensity. She states that her pain started an hour
ago with feeble intensity contractions which have increased in frequency and intensity in the last half an hour. She is Gravid 2, Para 1 and her previous pregnancy was
uncomplicated. On vaginal examination, the cervix is 90% effaced and 8cm dilated.

CUES/EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Objective: Risk for greater degree of Within my immediate care, Intrapartal Care (1st Stage After my 5-hour care of the
● 22 years old, G2P1 cervical and/or perineal Helen Guani will deliver of Labor) patient during active labor,
who presented with tears related to rapid the baby safely without any Independent: the objectives were met:
uterine contractions cervical dilation and fetal further complications as ● Assess carefully for ● To monitor how far ● Perineal tear was at
that started an hour descent evidenced by: dilation and the mother’s labor is. 2nd degree.
and a half ago: effacement ● Lochial flow was less
duration 4 min ● Inhibition of ● Assess vital signs, ● To check if the vital than 1 saturated
apart lacerations, if present, particularly BP, and as signs are within pad/hour
● 90% effaced to progress to a well as FHR acceptable range; to ● Client was alert,
● 8cm dilated higher degree. have baseline data. awake, and oriented
● Lochia flow of less ● Do not leave the ● To ensure the patient's to time, date, place
Subjective: than one saturated mother alone safety. and person.
● She states that, “her pad/hour postpartally ● Try to make the area ● To prevent nosocomial ● Maintained vital
pain started an ● Alert, awake, and sterile infections and further signs within normal
hour ago with oriented to time, date, complications. parameters.
feeble intensity place and person. ● Try to get the mother ● Panting relaxes pelvic ● Actively participated
contractions which ● Maintenance of vital in control -- Have floor muscles thereby during delivery
have increased in signs within normal mom pant to decrease helping the woman ● Prevented MgS04
 SILLIMAN UNIVERSITY
College of Nursing
Dumaguete City
NURSING CARE PLAN

frequency and parameters. the urge to push control the urge to toxicity.
intensity in the last ● Active participation push. ● Delivered the baby
half an hour” of the client. Collaborative: safely with
● Prevent MgS04 ● Administer MgSO4 if ● MgSO4 inhibits acceptable APGAR
toxicity. prescribed, and assess contraction by scores of 8 and 9.
● Safe delivery of the for MgSO4 toxicity. lowering Ca levels in
baby with an Have Ca gluconate uterine muscle cells.
acceptable APGAR nearby. Ca gluconate is the
score within the 1st antidote for MgSO4
minute and 5 minutes toxicity
after delivery. ● LR/DR personnel ● MGSO4 crosses the
must be alerted if the placenta in which the
MgSO4 was used baby may be born with
within 2 hours of birth. severe respiratory
depression.

(2nd, 3rd & 4th Stages of

Labor)
Independent:
● Apply gentle pressure ● Prevents rapid change
to the fetal head as it in pressure in the fetal
crowns head which can cause
subdural hemorrhage
or dural tears.
● Deliver the baby ● This controls the
between contractions delivery of the fetus
● Hold baby’s head low ● Skin-to-skin is
SILLIMAN UNIVERSITY
College of Nursing
Dumaguete City
NURSING CARE PLAN

and place on mother’s initiated to promote

abdomen thermoregulation of
the fetus.
● Clamp the cord once ● Delayed cord
pulsations have clamping is associated
stopped with significant
neonatal benefits.
● Allow to breastfeed ● Ensures that the infant
receives the colostrum,
or “first milk”, which
is rich in protective
factors
● Adequately assess ● Failure to recognize
degree of the extent of the
cervical/perineal trauma, an incorrect
trauma repair and inadequate
pain management
during and after the
repair may contribute
to major physical,
psychological and
social issues

● After labor, maintain ● Promotes recovery and

the ptx on bed rest reduces fatigue. Bed
with a leg elevation of rest is strongly
20-30 degrees. recommended in ptx
SILLIMAN UNIVERSITY
College of Nursing
Dumaguete City
NURSING CARE PLAN

who had a precipitous

labor to prevent
postpartum
hemorrhage; also
obtains good venous
return for improved
blood flow to the brain
and other vital organs;
also prevents edema.
Collaborative:
● Assist physician in
doing episiorrhaphy ● Is done to repair the
if needed. perineal trauma
brought by delivery.
 SILLIMAN UNIVERSITY
College of Nursing
Dumaguete City
NURSING CARE PLAN

CUES/EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Risk for fetal injury related Within my immediate care, Independent: ● During this Within my immediate care
● She states that, “her to precipitous labor the baby will have normal ● Continue to effectively unprecedented time, of the patient during active
pain started an progress and will be communicate with the families are very labor, the objectives were
hour ago with delivered safely as woman and her vulnerable. Adequate met as evidenced by:
feeble intensity evidenced by: support persons. information reduces ● Mother actively
contractions which ● Active participation by Support the family by anxiety to both the participated that led to
have increased in the mother to improve providing information woman and the support improvements of labor
frequency and labor pattern and/or on the condition, plan person(s). patterns, and also
intensity in the last reduce identified risk of treatment, reduced identified risk
half an hour” factors implications and factors.
● Display of FHR within explain the treatment ● FHR within acceptable
Objective: normal limits, with modalities. range and negative for
● 22 years old, G2P1 good variability, no ● Assess FHR manually ● Detects abnormal variable decelerations.
who presented with late decelerations or electronically, and responses, such as ● Oxygen levels within
uterine contractions noted. note variability, exaggerated variability, normal range.
that started an hour ● Oxygen levels within periodic changes, and bradycardia, and ● Delivered the baby
and a half ago: normal range (95-100) baseline rate. tachycardia, which may safely with acceptable
duration 4 min ● Fetus delivered safely be caused by stress, APGAR scores of 8
apart with an APGAR score hypoxia, acidosis, or and 9.
● 90% effaced of at least 7-9 sepsis.
● 8cm dilated ● Note frequency of ● This signifies adequate
uterine contractions. oxygenation of
intervillous spaces.
● Note uterine pressures ● Resting pressure
during resting and greater than 30 mm Hg
SILLIMAN UNIVERSITY
College of Nursing
Dumaguete City
NURSING CARE PLAN

contractile phases via or contractile pressure

intrauterine pressure greater than 50 mm Hg
catheter, if available. reduces or
compromises
oxygenation within
intervillous spaces.
● Carefully monitor fetal ● Precipitous labor
descent in the birth hastens fetal descent
canal in relation to thereby increasing the
ischial spines. risk of laceration
● Note color and amount ● Noting characteristics
of amniotic fluid when of amniotic fluid alerts
membranes rupture. staff to potential needs
of newborn, e.g.,
airway/ventilatory
support.
Dependent:
● Obtain fetal oxygen ● This supplies the
saturation level when information as to
ordered. whether the fetus is
becoming acidotic.

Collaborative:
● Plan the presence of ● Collaborative care
pediatrician and ensures safety to both
neonatal intensive care. the mother and the
fetus.
SILLIMAN UNIVERSITY
College of Nursing
Dumaguete City
NURSING CARE PLAN

● Be prepared for ● Other healthcare teams

neonatal resuscitation. who are skilled and
knowledgeable enough
should perform
resuscitation.
 SILLIMAN UNIVERSITY
College of Nursing
Dumaguete City
NURSING CARE PLAN

CUES/EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Risk for ineffective Within my 5-hour care, Independent: After my 5-hour care, the
● Claims that she has childbearing process Helen Guani will cope with ● Establish rapport with ● To gain patient’s goals were met as the
no partner and lives related to inadequate the process without the patient cooperation patient exhibited progress
with her parents support system complications and ● Assess the anxiety ● Establishes a baseline by:
who are against her experience less anxiety as levels of the ptx and observation of the ● Support systems such
situation evidenced by: anxiety triggers and anxiety level of the as friends, community
symptoms by asking ptx. Open-ended members were
Objective: ● Identification of open-ended questions. questions can help identified.
● 22 years old, G2P1 support system explore the thoughts ● Identified effective
who presented with ● Identification of and feelings of the ptx coping behaviors.
uterine contractions effective coping regarding the ● Performed effective
that started an hour behaviors. situational crisis. coping skills by the
and a half ago: ● Demonstration of ● Encourage ● Helps the nurse gain use of self-directed
duration 4 min effective coping verbalization of insight into individual techniques
apart skills by the use of feelings. needs, and assists the ● Engaged in activities
● 90% effaced self-directed client/couple to deal that maintain/enhance
● 8cm dilated techniques. with concerns. control.
● Engagement in ● Ensure to speak in a ● Calm voice and a ● Vital signs within
activities to calm and comfortable normal range
maintain/enhance non-threatening environment can help ● Seeking behaviours
control. manner to the ptx. the ptx feel secured from counselors and
● Vital signs within Maintain eye contact and comfortable to other mothers who are
normal range when communicating speak about his/her in the same situation.
● Verbalizations of with her. worries and fears.
seeking counseling ● Provide a comfortable ● Client may become
SILLIMAN UNIVERSITY
College of Nursing
Dumaguete City
NURSING CARE PLAN

once discharged. environment. more relaxed and open

for discussion if she
sees the nurse as calm
and appears to be in
control.
● Assist client in ● Strong support system
identifying other has many positive
support system benefits especially to a
postpartal woman who
may be at risk for
postpartum
depression.
● Provide positive ● Ensures that clear
reinforcement for information gets to the
efforts. Use touch and mother and partner.
soothing words of This might help reduce
encouragement anxiety levels.
● Provide factual and ● Encourages repetition
honest answers to of appropriate
questions regarding behaviors. Enhances
fetal status and the individual's
contraction pattern. confidence in own
ability to cope with or
handle labor, while
also meeting her needs
for dependency.
● Encourage the client to ● Conserves strength
SILLIMAN UNIVERSITY
College of Nursing
Dumaguete City
NURSING CARE PLAN

rest between needed for pushing,

contractions with eyes thereby facilitating the
closed. coping process
● Teach mother the ● Goal is maximum
effects of anxiety control of the anxiety
experienced on the experience to divert
process of labor and focus on successful
delivery delivery and birth of
the fetus.
Dependent:

● Administer ● Mild sedatives may

medications only provide tranquilizing
when approved by the and soothing effects to
LRDR team the patient. However,
these should be used
with extreme caution
during labor.
Collaborative
● Refer the woman to ● The woman may need
counselors that can counseling as she is at
council her with risk for developing
regard to her situation. postpartum depression
if she has no support
system.