Question

Create a care plan for Emily Boyde, a patient in active labor wirh her first child.

Answer 1

LABOUR

• Labour is defined as a series of rhythmic, involuntary, progressive uterine contraction that causes effacement and dilation of the uterine cervix. This process of labour and birth is divided into 3 stage

1. First stage of labour
2. Second stage of labour
3. Third stage of labour

• First stage of labour is the longest and involves 3 phases: latent, active and transition
• The latent begins with the onset of regular uterine contractions until cervical dilation.
• The active phase occurs when cervical dilation is at 4 to 7 cm and contraction last from 40 to 60 seconds with 3 to 5 minutes interval and the last phase which is transition phase occurs when contractions reac h their peak with intervals of 2 to 3 minutes and dilation of 8 to 10 cm
• The second stage of labour starts when cervical dilation reaches 10 cm and ends when the baby is delivered.
• The third stage or placental stage begins right after the birth of the baby and ends with the delivery of the placenta.

NURSING CARE PLANS

The nursing care plan for awoman in labor includes providing information regarding labor and birth, providing comfort and pain relief measures, monitoring mother's vital signs and fetal heart rate, facilitating postpartum care, and preventing complications after birth.

Here are 36 nursing care plan (NCP) and nursing diagnosis for the different stages of lobor including care plans for labor induction and labor augmentation

• Labor stage IA: latent phase

1. Deficient knowledge
2. Risk for fluid volume deficit
3. Risk for fetal injury
4. Risk for maternal infection
5. Risk for ineffective infection
6. Risk for anxiety

• Labor stage IB: Active phase

1. Acute pain
2. Impaired urinary elimination
3. Risk for impaired fetal gas exchange
4. Risk for maternal injury
5. Risk for ineffective individual/couple coping

• Labor stage IC:Transition phase

1. Acute pain
2. fatigue
3. Risk for decreased cardiac output
4. Risk for fluid volume deficit/ excess
5. Risk for ineffective coping

• Labor stage II: Expulsion

1. Acute pain
2. Altered cardiac output
3. Risk for impaired fetal gas exchange
4. Risk for fluid volume deficit
5. Risk for fetal injury
6. Risk for maternal infection
7. Risk for impaired skin integrity
8. Risk for ineffective individual copying
9. Risk for fatigue

• Labor stageIII:Placental expulsion

1. Acute pain
2. Knowledge deficit
3. Risk for fluid volume deficit
4. Risk for maternal injury
5. Risk for altered family process.

• Labor induced: Augmented

1. Acute pain
2. Knowledge deficit
3. Anxiety
4. Risk for impaired fetal gas exchange
5. Risk for maternal injury