Assessment diagnosis Planning intervention rationale evaluation

Subjective Data:  Shoulder After 24 hours of Independent: After 24 hrs. of

  having dystocia nursing  Establish a rapport to  Answers to effective nursing
contractions related to interventions:  enable the client questions can
intervention, the goal
and feeling gestational  The client partner to feel alleviate fear
uncomfortable diabetes will have a comfortable asking and promote was met:
as verbalize mellitus as stable vital questions. understanding.  The client's
by the client evidence sign  Evaluate pain noting  Provides vital signs
 G3 P2 by failure throughout characteristics, information were stable to
 as labor of cervical the labor location, and intensity about need normal range
prolonged to dilation, process (1-10 scale) for/effectivene
over 24 hours, prolonged  The client’s ss of throughout
mother is labor and baby will interventions. the labor
getting tired occiput- have a  Keep the patient  To reduce process
and as such is anterior stable vital informed to the status patient anxiety  The client's
pushing fetal head sign of labor baby vital
position without  Place the client into  It promotes the
Objective Data: Risk for fetal signs were
 McRoberts position for rotation of the
 cervix is 3 cm fetal injury distress pelvis to let the stable to
the McRoberts
dilated upon related to when in maneuver baby pass normal range
arrival obstructed labor through. without fetal
 fundal height labor  The client  Ask for assistance,  Shoulder distress when
is noted to be cervical make sure that there dystocia is an
in labor
40 cm dilation will are enough medical emergency
 pelvic improve that requires  As Oxytocin
members to support
ultrasounds after the fast was infused,
the delivery of the
were normal infusion of baby with shoulder recognition, the client
and antennal oxytocin dystocia intensive cervical
care was  The client monitoring and dilation was
unremarkable will be assistance will
 the baby was informed be needed.  improved
moving for possible  To release the  The client was
 Apply suprapubic
actively episiotomy compression and baby's informed and
normal prior to be able assist medical impacted agreed for
to labor. to deliver personnel for the shoulder when episiotomy to
 After 4 hours, the baby maneuver to deliver shoulder
spontaneous  The client
be able to
the baby dystocia is
rupture of will occurring deliver her
membranes successfull during labor baby
occurred y deliver  The client had
 the client the baby  Episiotomy is a successful
 Informed the client that
 cervix is at 3 without there may be a need of an incision delivery
cm upon fetal injury having episiotomy made in the without any
examination  The client perineum, the
fetal injury
 the fetal head will be able tissue between
position is at to discuss the vaginal  The client was
occipito- the pain opening and able to
anterior felt during the anus discuss the
position after the during pain felt
30 minutes of labor with childbirth so
during and
active pushing the pain the baby can
 diagnosed to scale of 1- pass through after the labor
have 10 easily. with the pain
gestational  Closely monitor  Monitoring scale of 7/10
diabetes maternal and fetal fetal status can
mellitus at 28 status. help doctors
weeks age of determine if
gestation pregnancy and
labor are
progressing
normally.
Changes in the
baby’s heart
rate can be a
sign of a
potential
problem.
 Demonstrate/  Reduces
encourage use of anxiety,
relaxation techniques, promotes
including patterned relaxation and
breathing. sense of
control,
assisting client
to cope
positively with
the situation

 Acknowledge
 Acknowledge reality of
reality of
client’s reports of
client’s reports
pain/discomfort.
of
pain/discomfor
 t.
Dependent:
 Give oxytocin infusion  Oxytocin is
as ordered by the use to begin or
doctor improve
contractions
during labor
thus will help
the process of
cervix dilation

 Promotes
relaxation,
 Give analgesic drug as relieves pain
ordered by the doctor and enhance
cooperation
with other
therapeutic
interventions.

Nursing diagnosis-

Risk for fetal injury related to obstructed labor.

Assessment-

Mother states that she is tired and does not know how much longer she is able to push.

Labor prolonged to over 24 hours, mother is getting tired and as such is pushing ineffectively and fetus has not descended into birth canal.

Expected outcomes-
Maternal patient will participate in interventions to improve labor so that the baby is delivered within 12 hours. Fetal patient will display a fetal heart rate within
normal limits with no later decelerations and will show no distress for duration of labor.

Nursing interventions-

1. Assess fetal heart rate electronically. Note the variability, periodic changes and baseline rate.

2. Monitor fetal decent in birth canal in relation to ischial spines.

3. Assess former position using leopold's maneuver and findings on internal examination.

4. Note order and colour of amniotic fluid once.

Rationale for the related interventions-

1. Detects abnormal responses which may indicate hypoxia or distress.

2. Lack of decent in the birth canal may indicate malposition.

3. In order to know potential dysfunctional labour it is necessary to determine the fetus is lie and position within the birth canal.

4. To know if there is meconium present to find out if the fetus is in distress.

Evaluation-

Maternal patient participated in the interventions to improve labour and the baby was successfully delivered 8 hours after mother was fully dilated and effaced.
Fetal patient maintains a normal range of heart rate and showed no decelerations or distress throughout the labour process.