Confused about this??

an l&d care plan is no different from a med/surg care plan. you still go through the same process for determining the nursing problems. you are just dealing with a different set of data that involves the gynecological system and the birthing process.

the first thing you need to do is assess that patient. you also need to know the birthing process and its pathophysiology just as you do for any other medical disease or condition. the only information you've provided in this post is all about the patient's medical conditions. we are nurses. we deal with how the patient responds and reacts to what is happening to them. so, when you assess the patient you think about what you know about the birthing process and what it does to the patient's body. think about what happens to the birth canal as a baby comes through it. does damage to the tissues occur? is that where some of the pain comes from? what happens when tissues are damaged? the inflammatory response sets in: redness, heat, swelling and pain. just because it is internal and you can't see it doesn't mean that it isn't happening. this is not different from a med/surg patient that comes in with some kind of physical trauma except we call it part of the normal birthing process. what else happens to the woman's body when that baby comes through the birth canal? how does it affect the bladder and the orifice? is she breastfeeding? there are 3 nursing diagnoses that involve breastfeeding whether things or going well or not. if you want to address the patient's substance abuse problem you care plan for it just as you would for a med/surg patient, but is it affecting the labor and delivery process? i get that you "feel" it needs addressing, but care planning and the nursing process is scientific and you have to address the evidence in front of you. if there is no evidence of a problem now, then leave it alone. you cannot begin to write nursing interventions until you have gone through your assessment data and found the abnormal data that is going to be the evidence of the nursing diagnoses you end up with. you will do nursing interventions for the symptoms of each nursing diagnosis.

acute pain r/t pitocin induced labor process

risk for maternal/fetal injury r/t obstetrical complications

potential for post partum hemorrrhage r/t cervical or lady partsl laceration or hypotonic uterus

If u want to do something for the substance abuse issue, how about complications related to the babys prenatal exposure to drugs? Depending on what drugs the pt was on- failure to thrive?

The problem is that the care plan is about the mother. You can't mix up mother and baby problems on one care plan.