Need Help with OB Nursing Dx

[missninaRN]

I need some wisdom and insight.

I had my first OB nursing clinical yesterday. The patient was a primigravida who had not attended childbirth preparation classes.

Pt was admitted at 1200 dilated to 2-3 cm, epidural was placed. Pt received 1 mg Stadol IVP at 1540 and 1620

Pt stated urge to have a BM at 1940 at which time cervix was complete and began to push.

Pt would push to count of 2 or 3, then would stop. Pt reported lady partsl pain, stated she couldn't push because it hurt too much. Pt refused to hold up her legs to push, flapped her hands in air and resisted pushing by straightening out her knees and pushing her feet against staff who were holding up her legs.

Staff attempted to redirect and educate pt regarding effective pushing between contractions, but pt continued to resist pushing throughout delivery.

Maternal vital signs remained within normal limits throughout labor, fetal heart rate remained reassuring with accelerations and good variability, no decels.

Pt was given novocaine to the perineum and a midline episiotomy at 2051. Time of birth 2052. Infant Apgar: 8 & 9.

Here are my initial ideas for a nursing diagnosis:

Pain r/t birth process

or

Anxiety r/t pain and lack of knowledge of birth process

or

Deficient knowledge r/t lack of education regarding birth process

or

Ineffective coping r/t pain and deficient knowledge of birth process

Is there a better nursing diagnosis that I'm not thinking of?

Thanks for any advice you can offer!

[Daytonite, BSN, RN]

You have a patient who:

• is a primigravida and has not attended childbirth preparation classes
  
• had epidural anesthesia
  
• had a midline episiotomy

You've got a first time mother who went into the birth process with no education about it, but she got through it. Is your care plan to be about her post-delivery period now that she has delivered the baby? Remember that any nursing diagnoses you decide upon are ALWAYS based upon the symptoms (defining characteristics) that you assess in this patient. You also need to review the normal physiology of labor and what typically is happening to all the surrounding tissues during the process of labor (there is a lot of tissue trauma going on internally due to the mother pushing the baby through a normally small tube--it leaves damage behind that you cannot see with your eyes, so your assessment skills must suffice). There are several things that you need to address.

1. She had epidural anesthesia. A temporary loss of feeling and movement to the lower part of the body is expected with this kind of anesthesia. Side effects include headache, backache, buzzing in the ears, convulsions, infection, persistent weakness and numbness in the lower extremities, residual pain from the injection, an injury to blood vessels during the epidural injection and transient temporary spinal headache. Some medication or the epidural itself can be the underlying cause of urinary retention.
   
2. She had an episiotomy. This is a surgical incision and interruption of tissue followed by suturing. It needs to be observed and treated as per the doctor's orders. You need to look up the assessment and nursing care of episiotomies. You didn't mention it, but if they did a rupture of her membranes she is at risk for an infection as a result of that procedure as well as because of the episiotomy. Also, the internal lady partsl tissues swell in response to all the activity of labor and the movement of the baby as it comes through the lady partsl canal.
   • Acute Pain R/T surgical trauma and tissue edema
     
   • Impaired Tissue Integrity R/T surgical interruption
     
   • Risk for Urinary Elimination R/T tissue edema, mechanical trauma and effects of anesthesia
     
   • Risk for Infection R/T surgical interruption of tissues

[*]After 8 or 9 hours of hard labor mothers are exhausted. They need rest and nourishment.

• Readiness for Enhanced Nutrition R/T maintenance of adequate intake to meet metabolic needs
  
• Fatigue R/T physical exertion during labor

[*]This patient, in particular, probably needs discharge teaching relating to the care of her infant, care of her episiotomy wound and, is she breastfeeding?

• Ineffective Breastfeeding R/T knowledge deficit, maternal ambivalence, material anxiety
  
• Knowledge Deficit (learning need) regarding postpartal care and childcare R/T lack of information, possibly lack of interest in learning or a cognitive deficit [this would depend on your assessment of the patient]
  
• Risk for Fluid Volume Deficit R/T long labor and inadequate fluid intake

Nursing diagnoses pertaining to the baby alone do not belong on a care plan being written about the mother. The care plan for the mother is about the care problems of the mother. The only effect on the baby might be the care the mother is going to be able to provide to the baby that you will need to enhance through teaching her proper methods of baby care. I didn't include any nursing diagnoses relating to a bonding relationship, but it had crossed my mind that a new mother who didn't attend prenatal classes may not be interested in caring for this baby (just a thought) and bonding with this baby may be a problem. Don't know what all the underlying history is here (which is why you have to get into these medical records and read all the information that is available) but it doesn't sound like this little baby is coming into a very good situation. However, the care plan, as I said, is about the mother, not the baby.

[missninaRN]

Thank you Daytonite! You have given me lots to think about. I appreciate your help so much.