DATE 18/12/08

NURSING DIAGNOSIS High risk for haemorrhage related to maternal soft tissue injury Secondary to invasive procedure

GOAL The patient will not bleed during delivery procedure and throughout hospitalizatio n

NURSING INTERVENTIONS Use the right size of vacuum head cup.

SCIENTIFIC RATIONALE A vacuum cup that is relatively bigger in relation to fetal head can cause trauma. Presence of maternal tissues between the cup and the fetal head can result in excessive vaginal tears when traction is being applied Unnecessary pushing will cause oedema that can potentiate tears. Incompetent application of traction can lead to cervical and vaginal tears. This will prevent cervical tears. Suturing controls bleeding.

EVALUATION Check the perineal pad every 30 minutes for evidence of active bleeding.

Exclude maternal tissues whenever vacuum pressure is being increased.

Instruct the client to push only when there is a contraction. Follow the curve of the birth canal when applying traction Start performing vacuum extraction when cervical dilation is 10 cm. Arrest bleeding by suturing if there is evidence of a vaginal or perineal tear

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Altered comfort pain related to uterine contractions as evidenced by strained facial expressions and verbalization.

Massage patients back. Client will experience minimal levels of pain throughout labor. Apply warm compress on the back Encourage slow rhythmic deep breathing

This stimulates the parasympathetic nervous system to send messages to the brain therefore reducing the sympathetic transmission to the pain centers on the back. Warm compress provides soothing effect thus reducing pain This provides some form of relaxation therefore muscle tension is released. This will act as a diversional therapy to prevent her from concentrating on the pain. This releases tension thus reducing pain. Warm bath has a soothing effect thus promoting relaxation. Pethidine blocks pain receptors thus reduces pain

Assess patients pain perception after 30 minutes of nursing interventions

If she can listen chat with the patient

Encourage the client to change positions frequently Give a warm bath in early stage of labour. Give pethidine 100mg intramuscularly.

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High risk for altered fluid and nutrition status related to slowed digestive functioning and emptying time of the stomach/ reduced food intake.

Client will have adequate fluids and nutrition throughout labour process

Give client light porridge in latent phase . If there are no restrictions of oral fluid intake give the client sips of water. Commence intravenous infusion of Dextrose 5% Moisten lips with Vaseline

Light porridge can easily be digested and can provide the necessary nutrients to the mother This will ensure adequate hydration status. 5% dextrose will provide fluids and energy to the mother Vaseline prevents excessive drying of lips by retaining moisture thus preventing insensible loss of water.

Check the lip and skin for hydration status hourly Check urine for ketone bodies

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High risk for infection related to invasive procedures during labour and ruptured membranes.

Client will be free from infection throughout the first stage of labour

Use aseptic techniques when performing procedures Minimise invasive procedures. Provide a clean working area and clean linen Provide a sterile pad when membranes rupture.

This will prevent Monitor body introducing infection to the temperature client every 4 hours because a rise in Unnecessary invasive body temperature procedures can introduce of more than 37.5 infection. degrees celcius will be suggestive Dirty linen is a medium for of infection. growth of microbes. This will control and prevent entry of microorganisms that can cause infection. This will reduce microorganisms that can cause infection. This will prevent development of infections

Clean the perineum when it gets dirty Give antibiotics to client if membranes have ruptured for more than 12 hours.

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High risk for bladder injury related to compression by the descending fetal head

Client will not sustain bladder injury throughout labour process

Empty bladder every 2 hours This will prevent trauma to Note the colour of or more depending on the the bladder. urine- should be needs of the client blood free. If the client is unable to pass urine insert an indwelling catheter. This will keep the bladder empty thus preventing trauma Check the amount of urineshould not be less than 30mls/hour.

18/12/08

High risk for fetal hypoxia related to compression of the placenta during uterine contraction.

The fetus will have adequate oxygen throughout first stage of labour

Teach the client relaxation technique e.g. rhythmic breathing Encourage the client to lie laterally

This will make the client relax and maintain adequate supply of oxygen to the fetus This position will prevent compression of inferior vena cava and aorta thus promoting adequate supply of oxygen to the fetus and uterus.

Monitor fetal heart rate half hourly.

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High risk for trauma to the fetal head related to invasive procedure

The baby will not sustain injury throughout the procedure

Rule out all the contraindications before performing the procedure Start performing the procedure when the cervix is fully dilated

Overlooking the contraindications can result into trauma to the fetal head This will minimize chances of trauma to the fetal head.

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