LABOR AND DELIVERY

MED CARDS: Pitocin, Terbutaline, Magnesium Sulfate, Fentanyl

1.

DIAGNOSIS: Acute pain related to progress of labor.

GOAL:

The client will be able to tolerate pain as evidenced by: verbalization, decreased facial
grimacing, and decreased muscle tension, able to follow simple instructions.

INTERVENTIONS:
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4.
5.

2.

Position client for maximum comfort. Tell her that while her comfort is very important, her
baby's safety is also. Assure her that I will try to help her to find laboring positions that are both
safe for the fetus and comfortable for her. Let her know that not always are both objectives
possible and that I'll continue to let her know about her baby's well being.
Assist the client with relaxation techniques such as guided imagery, effleurage, and
environmental control.
Give the support person permission to be active in his/her role. Demonstrate ways that this
person can help the client such as coaching her breathing, helping her with her legs, applying
counter pressure over her sacrum, mopping her brow, communicating her needs to others.
Encourage the client to walk around as she labors, take a jacuzzi/shower, or sit in a rocking chair
to the extent that it is safe for the fetus.
Tell her about her pain relief options and give her permission to change her mind about decisions
she may have made from a standpoint of ignorance.
DIAGNOSIS: Alteration in fetal tissue perfusion related to maternal position, epidural,
oxytocin, rupture of membranes.

GOAL:

Fetus will be adequately perfused as evidenced by reassuring fetal monitor and absence
of late decelerations, excessive variables, or baseline changes.

INTERVENTIONS:
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6.

3.

Assess fetal monitor for reassuring signs every 15 -30 minutes.

For non-reassuring fetal heart pattern, stop oxytocin infusion immediately.
If problem persists change patient's position: first to one side, then to the other.
If problem persists, increase IV fluid (one would probably do this first if the woman is
hypotensive following epidural dosing)
If the problem persists, provide oxygen by mask at 10 liters.
If the problem persists, notify physician or nurse midwife immediately and prepare for possible
cesarean section.
DIAGNOSIS: Potential for infection related to rupture of membranes.

GOAL:

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6.

Client will be free of infection as evidenced by: Maternal temperature remains WNL
during labor and fetal heart rate remains between 120 and 160.
Begin taking temperature every 2 hours after rupture of membranes and more often as indicated.
Monitor fetal heart rate continuously.
Exercise good hand washing.
Frequently change underpads.
Cleanse vulva from front to back when giving peri-care during labor.
Provide IV antibiotic during labor for temperature at or greater than 38 degrees Celsius

POSTPARTUM
MED CARDS: Tylenol #3, Percocet, Colace, Motrin, Methergine, Toradol, Pitocin
1.

DIAGNOSIS: Potential fluid volume deficit secondary to excessive bleeding.

GOAL:

Client will experience bleeding within normal limits as evidenced by: soaks less than one
pad per hour.

INTERVENTIONS:
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2.
3.
4.
5.
2.

Turn client to side-lying position with top leg flexed and bottom leg outstretched. Observe
amount of bleeding on peri-pad, chux. Inspect perineum/vulva for hematoma/laceration.
Palpate fundal height. Massage/crede as needed to maintain a constricted uterine fundus at
umbilicus. (deviation from midline suggests a full bladder.)
Assist client to maintain an empty bladder either by assisting her to use the bathroom, bedpan, or
through use of a urinary catheter.
Assess vital signs per protocol and as needed to assure ongoing hemodynamic stability.
Provide oxytocin/cytotec as needed to manage excessive bleeding.
DIAGNOSIS: Altered family process related to role changes.

GOAL:

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3.

Family members will demonstrate adaptive behaviors as evidenced by assumption of new

role behaviors.
Assess current role behaviors as they relate to the client and infant and reinforce adaptive
behaviors.
Give family members permission to assume new roles.
Demonstrate ways in which family members can welcome the infant and support the physiologic
and psychologic needs of the mother.
Ask for return demonstrations for any tasks family members will be performing.
Refer to social services if family function is severely impaired by inability to meet the needs of its
members.
DIAGNOSIS: Knowledge deficit related to self-care/breast-feeding.

GOAL:

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5.

The woman will demonstrate self care and breast-feeding techniques that are believed to
positively impact postpartum outcomes.
Assess current knowledge about self care and breast-feeding and reinforce positive behaviors.
Describe and ask for return demonstration of care of the perineum, including hand washing,
wiping front to back, using a peribottle, frequent changing of peri pads, and utilization of sitz
baths.
Discourage sexual intercourse and use of tampons until after the first postnatal check up (in about
6 weeks).
Discuss and ask for return demonstration of breast care techniques including using lanolin on the
nipples but not using soap or alcohol. Alternating breasts at feedings, wearing supportive bra,
breaking the baby's suction before removing from breast.
Discuss the psychologic and physiologic reasons for mood changes. Ask client to call for help if
"baby blues" becomes more than normal. Describe normal parameters for her. Provide numbers.

NEWBORN
MED CARDS: Vitamin K, erythromycin ophthalmic ointment
1.

DIAGNOSIS: Ineffective breathing pattern related to immature breathing center,

impaired gas exchange and fatigue
GOAL:

Infants breathing efforts will be more effective as evidenced by: no cyanosis, no nasal
flaring, no sternal retractions, no expiratory grunting

INTERVENTIONS:
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5.

2.

Clear the nose and mouth of mucous, place infant in a position that allows lung expansion and
reduces risk of aspiration.
Keep infant warm and dry to reduce the oxygen consumption.
Group treatments to allow uninterrupted time for rest
Administer oxygen and monitor carefully
Gavage feed infant if respiratory rate is greater than 50 to 60 per minute to decrease possibility
of aspiration
DIAGNOSIS: Potential for infection related to prolonged rupture of membranes,
elevated maternal temperature in labor and delivery, strep B vulvar colonization,
umbilical cord, and nursery stay.

GOAL:

Infant will be free of infection as evidenced by: temperature is neither high nor low,
infant is acyanotic, infant is able to feed, is not lethargic or irritable, respirations 30-60,
heart rate 120-160, fontanelles remain flat, no diarrhea or jaundice.

INTERVENTIONS:
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3.

Hand washing by nursing staff

Thorough and frequent cleaning of equipment.
Protect the umbilical cord from rubbing against the diaper.
Know maternal infection history including temperatures during labor and delivery. Give
antibiotics as needed. (get an order if indicated)
Observe for above named signs and symptoms of infection and rule out other causes.
DIAGNOSIS: Potential alteration in nutrition related to ineffective sucking

GOAL:

The infant will have adequate intake of nutrients as evidenced by: consumes
3.5oz/kg/24h (formula providing 20 kcal/0z) or if breast-feeding, wets 6-10 diapers per
day and urine remains clear (not brown or orange)

INTERVENTIONS:
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5.

Remove excess mucus from nose and mouth.

Have infant suck on clean gloved finger to assess and stimulate suck reflex.
Use wakeful periods for feeding.
Show the woman how to provide adequate breathing space for the infant.
Help the woman position the newborn to face her body and to take the entire nipple if breastfeeding.