Antepartum High Risk IMPLEMENTATION
 Close Maternal and Fetal monitoring, BP
ASSESSMENT
 Assess BP in sitting and left lateral position,
changes in level of consciousness, weight,
FHT and vaginal bleeding.
NURSING DIAGNOSIS/ES
 Fluid Volume Excess, Activity Intolerance
PLANNING
 Promote bedrest and environment, ensure
high protein intake and administer
Antihypertensive drug.
monitoring, S/S of pre-eclamsia, Vaginal or
Cesarean birth
EVALUATION
 Evaluate the mother and the infant
(physiologic and psychologic parameters.
Fetal distress
Fetal heart rate less than 120 beats/min or greater
than 160 beats/min due to decrease perfusion of
oxygen to the fetus.
ASSESSMENT
 Meconium-stained amniotic fluid, Fetal
hyperactivity, Severe variable decelerations
NURSING DIAGNOSIS/ES
 Pain, Ineffective Tissue Perfusion
PLANNING
 Have a delivery tray available (hemostats,
scissors, and cord clamp)
IMPLEMENTATION
 Lateral position, Administer oxygen, and
Discontinue oxytocin if infusing.
EVALUATION
 Evaluate the mother and the infant
(physiologic and psychologic parameters)
Prolapsed Umbilical Cord
•A loop of the umbilical cord slips down in front
of the presenting fetal part
•The umbilical cord is displaced between the
presenting part and the amnion or protruding
through the cervix, causing compression of the
cord and compromising fetal circulation.
 ASSESSMENT
 Lack of engagement at the beginning of
labor, a prolonged first stage of labor
NURSING DIAGNOSIS/ES
 Pain, Powerlessness
PLANNING
 Have a delivery tray available (hemostats,
scissors, and cord clamp), Surgical Trays
IMPLEMENTATION
 Cesarean birth
EVALUATION
 Evaluate the mother and the infant
(physiologic and psychologic parameters)

Alterations in “Powers”
ASSESSMENT Premature labor
 Feeling that something is coming through  Preterm/premature labor occurs after the
the vagina, Umbilical cord is visible or twentieth week but before the thirty-seventh
palpable week of gestation.
NURSING DIAGNOSIS/ES
 Pain, Ineffective Tissue Perfusion
PLANNING
 Have a delivery tray available (hemostats,
scissors, and cord clamp)
IMPLEMENTATION
 Elevate the fetal presenting part that is lying
on the cord, Trendelenburg’s or modified
Sims’ position or a knee-chest position
EVALUATION
 Evaluate the mother and the infant
(physiologic and psychologic parameters)

Alterations in “Passageway”
Cephalopelvic disproportion

Inability of the fetal head to pass through the

maternal pelvis due to a discrepancy in size
ASSESSMENT
 Pelvic pressure or heaviness, Rupture of
amniotic membranes, Uterine contractions
NURSING DIAGNOSIS/ES
 Pain, Fluid Volume Deficit
PLANNING
 Have a delivery tray available (hemostats,
scissors, and cord clamp)
IMPLEMENTATION
 Focus on stopping the labor, Administer
fluids, Tocolytics
EVALUATION
 Evaluate the mother and the infant
(physiologic and psychologic parameters)
 Uterine Rupture
•Uterine rupture occurs when a uterus undergoes
more strain than it is capable of sustaining.
Rupture occurs most commonly when a vertical
scar from a previous cesarean birth or
hysterotomy repair tears.

ASSESSMENT
 Contractions may stop or fail to progress,
Signs of maternal shock, Fetus palpated
outside the uterus (complete rupture)
NURSING DIAGNOSIS/ES
 Pain, Impaired Tissue Perfusion, Fluid
Volume Deficit
PLANNING
 Have a delivery tray available (hemostats,
scissors, and cord clamp)/Surgical Tray
IMPLEMENTATION
 Monitor for and treat signs of shock, Prepare
client for cesarean delivery
EVALUATION
 Evaluate the mother and the infant
(physiologic and psychologic parameters)