Nursing care plan for active labor

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Introduction

Active labor is a crucial yet exciting stage in the labor and delivery process. It’s the part when the real work begins and the expectant mother needs special attention. A good nursing care plan for active labor not only ensures the safety of the mother and the baby, it also helps reduce stress and manage pain during the delivery procedure.

Assessment

The assessment phase involves the evaluation of current health conditions, the level of labor progression and identify the risk factors that affect labor progress.

• Assess contractions: Reassure the mother to focus on her breathing and push during contractions.
• Assess FHR: Monitor the Fetal Heart Rate (FHR) responses consistently to assess fetal response.
• Assess progress of cervical dilation: Monitor the mother’s cervical dilatation to determine the progress of labor.
• Assess fetal position: Assess the fetus position to determine any obstructions in the birth canal.

Nursing Diagnosis

The aim of nursing diagnosis for the active labor patient is to provide comfort and promote safety before, during, and after delivery.

1. Fear/Anxiety related to labor and delivery: Provide emotional support to the mother with positive phrases and talk her through each step of the process.
2. Pain related to contractions: Provide therapeutic measures like back rubs, position change and relaxation exercises including music, guided imagery, and aromatherapy.
3. Impaired Fertility related to physical changes: Promote comfort measures to reduce muscle tension like massages and assist in accessing breastfeeding method to support her fertility.*
4. Ineffective Coping related to unknown processes: Normalize the process and provide education about the stages of labor, pain perception and strategies to cope with the pain.

Outcomes

The goal of the nursing outcomes is to ensure the safety of the mother and baby before, during and after the delivery. The following goals should be achieved:

• Encourage safe delivery process.
• Provide adequate pain relief measures.
• Promote regular fetal monitoring.
• Achieve progress of labor effectively.
• Reduce anxiety, fear and enhance coping skills.

Interventions

The following interventions are necessary to deliver comprehensive care and achieve successful outcomes in active labor.

• Encourage safety: Utilize protective collars, positioning devices, and protective pads to avoid injury.
• Educate and inform: Regularly provide information about the process, facilitate decision-making, and offer guidance.
• Evaluate vital signs: Monitor blood pressure, temperature, pulse, respirations and fetal heart rate regularly.
• Comfort measures: Comfort measures like warm baths and position changes can help reduce the pain.
• Pain reduction: Pain reduction medications can be administered as prescribed by a physician.

Rationales

The nurse should be aware that interventions can be used to reduce the pain and stress of active labor and delivery, which can be beneficial for both the mother and the baby.

• Encouraging safety through the use of precautionary measures will protect the mother from any injury during the labor and delivery process.
• Educating and informing the patient about the labor and delivery process helps reduce anxiety, fear, and enables the patient to make informed decisions.
• Monitoring vital signs helps to detect any health issues with the mother and the fetus and aid in providing appropriate treatment if needed.
• Engaging in comfort measures like warm baths, position changes, massage, and adequate rest aids in reducing the distress and discomfort experienced during labor and delivery.
• Using medications can reduce the intensity and duration of labor contractions and pain.

Evaluation

The nurse should evaluate the effectiveness of the nursing intervention. The goal and objectives of the nursing care plan should be achieved successfully. The nurse should identify any problems or issues with regards to labor and delivery process.

Conclusion

Nursing care plans for active labor have a very important role in ensuring a safe and healthy delivery.

It provides a systematic approach to labor and delivery from the evaluation to assessment, diagnosis, interventions and outcomes. The nurse must be familiar with the labor and delivery stages and intervening strategies to provide comprehensive care for the mother and the baby.

FAQS

1. What is active labor? Active labor is the stage during labor and delivery when the cervix dilates up to five centimeters. It is often referred to as the second stage of labor.
2. What is the purpose of the nursing care plan? The purpose of the nursing care plan is to provide comprehensive care for the mother and baby during active labor. The plan involves assessment, diagnosis, interventions, outcomes, and evaluation of labor and delivery progress.
3. How can I reduce fear and anxiety during labor and delivery? Fear and anxiety can be reduced during labor and delivery by providing the mother with reassurance, emotional support, positive phrases, and distraction techniques like music, guided imagery, and aromatherapy.
4. What are the common interventions used in active labor? Common interventions used in active labor include encouraging safety, educating and informing about the labor process, evaluating vital signs, providing comfort measures and administering pain-relieving medications.
5. What are the goals of the nursing care plan? The goals of the nursing care plan are to encourage safe delivery process, provide adequate pain relief, promoting regular fetal monitoring, achieving progress of labor, and reducing fear, anxiety and promoting effective coping measures.