NURSING DIAGNOSIS FOR

ANTEPARTUM, INTRAPARTUM AND

POST PARTUM PERIOD
ANTEPARTUM PERIOD
( PATIENT ADMITTED)
• Health seeking behaviors related to special care
necessary during ante partum period as
evidenced by:

(what are the subjective and related objective data

which are indicative of a health seeking
behavior? Eg: frequently asks questions, not
being able to follow instructions, the need for
one with one supervision)
• Knowledge deficit on progress of labor (see
Health seeking behaviors for related matters.)
• Altered Health Maintenance related to (self-
care, nutritional needs, sleep etc) secondary to
false labor
• Altered nutrition, less than body requirements
related to standing order of NPO (Nothing Per
Orem)
• Anxiety related to perceived threat on progress
of labor
• Ineffective coping related to (anxiety being
experienced by the patient, unmet needs,
inadequate coping methods or support systems)

• Alteration in comfort: abdominal/ lumbar pain

related to progress of labor and delivery

• Sleep pattern disturbance related to

(discomforts in labor/ new environment)

• Energy field disturbance related to (increase

anxiety or pain)
• Difficulty adapting and coping with stress
related to labor (false or true)

• Risk for complications (identify the complication

and put evidences)

• Risk for maternal injury related to response to

therapeutic intervention or adverse effects of
delivery

• Risk for altered urinary elimination related to

reduced fluid intake
INTRAPARTUM PERIOD
• Alteration in comfort: (identify the site-
abdominal radiating to the back, lower back or
lumbar pain) related to the progress of true
labor
• Risk for fluid and electrolytes imbalance related
to maternal fluid loss during delivery
• Fatigue related to labor and delivery
• Risk for reduced tissue perfusion related to
maternal bleeding (only if with profuse bleeding
during delivery)
• Ineffective bearing down during delivery related
to inappropriate techniques used

• Risk for altered skin integrity related to

laceration of cervical or perineal tissues
POST PARTUM
• Fatigue related to delivery process

• Risk for infection related to presence of perineal

(laceration or incision) (if incision- put secondary to
episiotomy)

• (Risk or Actual) Fluid volume deficit related to fluid

loss during delivery

• Alteration in comfort, pain at the perineal area

related to episiotomy and episiorraphy

• Risk for constipation related to reduced fluid intake

• Sleep pattern disturbance related to (anxiety,
demands of NB care, etc)

• Ineffective breastfeeding related to (poor

sucking reflex of infant, inverted nipples, etc)

• Knowledge deficit on (maternal care or child

care)

• Body image disturbance related to the

physiologic changes of pregnancy evident after
birth
• Personal identity disturbance related to new
parental role

• Impaired parenting related to (new parental role

or lack of knowledge related to parenting)

• Risk for impaired parent infant attachment

related to adjustment to new parental role

• Sexual dysfunction related to post partum

trauma

• Ineffective family coping related to the delivery

of a new family member
Monitoring of progress of Labor
Delivery
Nursing Implementation or Nursing Responsibilities

First Stage of Labor:

• On admission to the labor unit:

 Greetings: Introduce Self.

 Admit client: Orient to physical setting. Review

common procedures so the patient knows what to
expect.
• Take history: Determine
Gravidity /Parity
EDC
Last meal
Allergies
Onset of Labor: Onset, frequency, duration of
contractions
 Status of the bag of waters
Intent to breastfeed

• Assess client’s knowledge about labor, whether

or not she had childbirth preparations.
• Take initial vital signs and FHT.

• Do Leopold’s Manuever (LM):

- Empty bladder , flex knees, warm hands
 LM 1 – palpate fundus; check for breech or
cephalic; usually breech – soft, globular, non
ballotable.

LM 2 – palpate sides of the abdomen; check for

smooth resistant back and irregular, small fetal
parts of the fetus. The area of the fetal back is
the best site for FHT auscultation.
LM 3 – palpate area just above the symphysis
pubis; check for cephalic or breech, usually
cephalic – check position and mobility of the
head.

LM 4 – palpate the midline, downwards and just

about 2 inches from the Poupart’s ligaments;
check for position and descent of the head
including degree of flexion.

• Perineal preparation; observe principles of

asepsis.
• Render enema if ordered – never a routine
procedure. Done to prevent:
Infection
Retardation of labor progress
Postpartum discomfort

• Obtain specimens for lab tests; urine for sugar

(negative in labor), protein (negative), acetone
(negative); Blood for hemoglobin (Hgb),
Hematocrit (Hct), white blood cells (WBC),
venereal disease research laboratory (VDRL),
cross matching.
• Monitoring:
Uterine contractions (progress of labor)
Bladder
FHT
Perineum – show
Rupture of BOW
Presenting part
Bulging
Cord prolapse
Bleeding
Ability to manage pain
BP, PR and RR: every hour in the latent and
active phases and every 30 minutes in the
transition phase if in normal range

Temperature: every 4 hours if normal range;

every hour if above 37.5°C or if membranes
ruptures. The leading complication of prolonged
rupture of the bag of water is infection.

FHR: every 30 minutes in the latent phase, and

every 15 minutes in the active and transition
phases if normal characteristics are present. If
with electronic fetal monitor, assess for reactive
nonstress test (NST).
• Prevent SHS (supine hypotensive syndrome);
position client on left lateral recumbent.

• Provide physical and psychologic comfort and

support.
Comfort measures:
o Assisting with positional change
o Keeping clean and dry
o Promoting sleep and adequate rest

Distraction – is one of the methods to increase

relaxation and cope with discomfort of labor
when contractions are mild to moderate.
Forms of distraction include:
Conversation
 Light activities as reading, card play, table
games
Ambulation not only distracts effectively but
also enhances labor progress.
Concentration on a pleasant experience
Visualization. The woman can visualize her body
or perineum relaxing.
Massage: Effleurage – a light abdominal
stroking, may be used in the first stage of labor
to maintain relaxation of the abdominal muscle;
effective for mild to moderate pain.

Back pain associated with labor may be relieved

from firm pressure on lower back or sacral area.
In the presence of an abnormal position,
occipitoposterior position, backache is unusually
severe. To manage, repose the mother to her side
side and with a fisted hand, apply a counter
sacral pressure.
• Promote Safety: Monitor for danger signals:
Strong or weak contractions (hypertonic or
hypotonic uterine inertia)

Bleeding (placenta previa, abruptio placenta,

uterine rupture)

Passage of meconium-stained amniotic fluid in

cephalic presentation (fetal distress)

Severe headache, dizziness, blurring of vision

(pregnancy induced hypertension)
 The Second Stage of Labor:
Delivery Stage
Nursing Implementation / Nursing Responsibilities
• Comfort to offer psychological support; inform of
progress
P - raise
R - eassurance
E - ncouragement
I - nform the mother of progress
S - support system
T - ouch
• Assist / Coach: Bear down only when needed,
during contractions.

• Monitor FHT at intervals (midway between

contractions). If there is continuous fetal heart
electronic monitor, check FHT during and after
a contraction; be alert for late decelerations.

• When to transfer patient to delivery room?

- Primigravida: cervix 10 cm with certain degree
of bulging with contractions.
- Multigravida: cervix 8 to 9 cms.
• Proper position: Lithotomy. Some
considerations:
- Padded stirrups
- No pressure on political region
- Equal height of legs
- Simultaneous placing of legs on the stirrup
o Alternate positions: Fowler’s side-lying or
squatting, as desired, indicated or supported by
unit policy.

• Perineal preparations: front to back motion.

• Provide assistance to the health provider in
attendance, or assist with deliver as indicated:
- With extension of the head Right away:
Feel the nape for any cord coil (lift cord and pass
over the head of the baby if present, double
clamp and cut if tight.)

Clear mouth and nose with shallow suctioning

using a bulb syringe to prevent meconium
aspiration.
• With expulsion: Delay clamping and cutting of
the umbilical cord until cord pulsations
disappear.

• Dry and wrap infant in a warm towel to keep

him warm. Placing the wrapped newborn on the
maternal abdomen can:
o Warm the newborn as the mother’s abdomen
has the same temperature as the incubator;
o Contract the uterus because of the baby’s weight;
and
o Promote mother – child closeness or bonding.
• Show baby to mother; ensure eye to eye contact
for bonding; verbalize similarities; allow
touching, stroking.

• Proper Identification is done before transferring

newborn to nursery or before separating from
the mother; a legal and ethical responsibility of
the nurse.
 The Third Stage of Labor:
Placental Stage
Nursing Implementation / Nursing Responsibilities
• Observe the principle of placental delivery stage:
Watchful waiting – watch and wait for signs of
placental separation) and not doing fundal
pressure with pull at the cord, especially if the
uterus is relaxed, as these actions could cause
inversion of the uterus, a lading cause of
hemorrhage in the third stage of labor.
• Gradual delivery of the uterus

• Inspect the placenta for completeness (First

nursing action after placenta is delivered).
Complete cotyledons
Complete cord vessels; 1 vein, 2 smaller arteries
Complete membranes

• Feel the fundus for contraction or firmness.

“soft”, “boggy” and “non-palpable”
- Mean uterine atony.

The initial activity of the nurse is to

massage fundus until firm.
• Ice cap may be applied to further contract the
uterus but never hot water bag.

• Inject ordered oxytocin after placental delivery.

Commonly used drugs:
Methylergonovine maleate – Methergine
Ethylergonovine maleate – Ergotrate

Action: to increase uterine motor activity by

direct stimulation
Target: Uterine Musculature
Indication: to prevent postpartum bleeding
from uterine atony and subinvolution

Evaluation of its effects: look for a firm fundus.

Side effects: nausea, vomiting, dizziness,

headache, hypertension, tinnutis,
hypersensitivity

• Assess VS, presence of lacerations, complete

placenta, bleeding

• Lower legs slowly

• If allowable by hospital policies, allow mother
time with infant to promote attachment or
bonding; breastfeed right on the delivery table.
 The Fourth Stage of Labor:
Recovery Stage
Nursing Implementation / Nursing Responsibilities
• Monitor VS every 15 minutes until stable; report
abnormal fluctuations.

 Blood Loss during delivery averages 250 ml with

the normal upper limit of 500 ml. Postpartal
bleeding is defined as the lost of 500 ml of blood
and more.
Because of the blood loss and the lifting of the
gravid uterus from surrounding vessels, blood is
redistributed into venous beds. This results to a
moderate drop in both systolic and diastolic
pressure, increased pulse pressure and slight to
moderate tachycardia.

• Palpate fundus every 15 minutes; check fundal

height, position in relation to the umbilicus and
consistency.

Before any fundal palpation is done, ask the mother

to void to ensure an empty bladder. This will not
only promote maternal comfort but will favor
accurate findings from palpation.
• In the recovery stage, the fundus is firm,
midline, and at the level of umbilicus.

o If relaxed, massage until firm. Do not over

massage as this can tire the uterine muscles,
causing relaxation.

o If displaced to the side, the first nursing nursing

action is to feel the lower abdomen for a
distended bladder. When the bladder is
distended, stimulate voiding.
• Assess lochia.
In the fourth stage, lochia is bright red and can
saturate 1 to 2 perineal pads in one hour. A
reddish color may be maintained for more than
2 weeks, but it when it persists for more than 2
weeks, it indicates either the retention of small
portions of the placenta or imperfect involution
of the placenta site or both.

• Check for bladder distention; determine first

voiding and voiding pattern. A full bladder
displaces the uterus to the side, a factory to
uterine atony.
• Checking the perineum; note general
appearance, redness, swelling, bruising, vaginal
and suture line bleeding.

• Administer oxytocin medications of ordered.

Check BP before and at intervals after; monitor
fundal contractions and lochia after
adminstration.

• Check episiotomy wound or lacerated wound for

bleeding, hematoma or edema. Ice bag to
perineum immediately after delivery (and in the
first 24 hours) can reduce edema and swelling.
• Promote sleep and comfort.

 Keep warm. Chills are common in the fourth stage of

labor. Causes of chills:
Maternal excitement
Sudden drop in maternal hormones
Release of intra-abdominal pressure
Fetal blood in circulation

• Give partial bath, peri-care (front to back), change wet

linens.

• Assess for after pains; reassure it is secondary to uterine

contractions; icecap for relief or analgesic as ordered.

• Provide nourishment as the woman may be thirsty and

hungry.