REPUBLIC of the PHILIPPINES

City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
_____________________________________________________________________________________
CENTER OF NURSING
NAME OF STUDENT: RAMOS, Louwella Faith M. YEAR/GROUP: II-BN CONCEPT: Maternal and Child Nursing
AREA: Deliver Room DATE: 2 March 2021

CUES/DATA NURSING INTERFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Risk for Fetal Labor is considered normal when uterine  
Mother states she is injury related to contractions result in progressive dilation The Maternal Independent:
and effacement (stretching and thinning)
tired and does not prolonged labor. of the cervix. Normal labor progresses
Patient will The Mather
know how much slowly through the initial (latent) phase participate in Assess FHR Detects Patient
longer she is able to and then, when the cervix is dilated more interventions to electronically. abnormal participated in the
push. than four centimeters, the more rapid, improve labor so Note variability, response which interventions to
active phase of labor begins. During that the baby is periodic changes, may indicate improve labor
active labor, the cervix should
progressively dilate at a rate of no less
delivered within and baselines rate. hypoxia or and the baby as
Labor prolonged to than 1.2 cm per hour (during a woman’s 12 hours. distress. successfully
over 24 hours; first pregnancy) or 1.5 cm per hour (for delivered 6 hours
mother getting tired subsequent pregnancies) (1). If labor Fetal patient will Monitoring fetal Lack of Descent after mother was
and as such is progresses more slowly than this, a display a fetal descent in birth in the birth canal fully dilated and
woman may be experiencing arrested or
pushing heart rate within canal relation to may indicated effaced fetal
prolonged labor.
ineffectively. Fetus normal limits, ischial spines. malposition. patient
has not descended Prolongation and arrest of labor are with no late maintained a
into birth canal primarily due to conditions that cause decelerations, normal range of
mechanical impediments or inadequate and will show Assess for In order to heart and showed
contractions, both of which are discussed
no distress for malposition using determine no decelerations
in this section.
Fetal malpresentation: If the baby is the duration of Leopold’s potential or distress
Vital Signs: not in the cephalic (vertex) position (in labor. Maneuvers and dysfunctional throughout the
-BP 90/60 mm of Hg which the head is at the lower part of the findings on labor, it is labor process.
abdomen) before birth, issues with labor
-PR 78 bpm progression can occur.
internal necessary to
-RR 16 cpm examination. determine the
-Temp 36.6 Cephalopelvic disproportion (CPD): fetus’s lie and
-Weight 51kg CPD occurs when there is disproportion position within
- Height 150cm between the size of the fetus and the size the birth canal.
of the maternal pelvis. This size
mismatch can cause labor to slow or stop
After the 2 hours
completely. of nursing
interventions, the
Problems with uterine contractions: Collaborative: patient will be
Inadequate uterine activity occurs when able to:
contractions are either not sufficiently
strong or not appropriately coordinated
Note odor and This can rule
enough to dilate the cervix and push the color of amniotic out. Manifest
baby out. Issues with uterine activity can fluid once. reduction of core
arise due to a pregnancy with multiples, temperature from
excessive use of painkillers or 38.9 to a normal
anesthesia, or a variety of other factors
range of 36.5C -
.
Maternal obesity: Higher maternal BMI 37.5 C
(body mass index) is correlated with a
longer first stage of labor, as well as a
variety of other pregnancy
complications.

Source:
https://www.abclawcenters.com/practice
-areas/prenatal-birth-injuries/traumatic-
birth-injuries/prolonged-and-arrested-
labor/