3 Precipitous Labor Nursing Care Plans

September 23, 2016

Precipitous labor occurs when the uterine contractions are so strong that the woman is able to give birth with just a few, rapidly occurring contractions. This kind of labor only lasts for not more than 3 hours. Because the contractions are so forceful, premature separation of the placenta may occur and the woman might feel overwhelmed with the speed of labor.

Nursing Care Plans

The nursing care for patients with precipitous labor revolves around promoting maternal and fetal well-being, prevention of complications, and providing a safe delivery.

Here are three (3) nursing care plans and nursing diagnosis for precipitous labor:

Risk for Deficient Fluid Volume

Deficient Fluid Volume: It is defined as decreased intravascular, interstitial, and intracellular fluid.

Risk factors:

Loss of fluids through normal routes
Forceful contractions
Premature separation of the placenta

Possibly evidenced by:

Significant blood loss due to premature separation of placenta
Decreased electrolyte level

Desired outcome:

Patient will identify individual risk factors and appropriate interventions.
Patient will demonstrate behaviors or lifestyle changes to prevent development of fluid volume deficit.

Nursing Interventions	Rationale
Note client’s level of consciousness and mentation.	To evaluate ability to express needs.
Monitor intake and output balance.	To ensure accurate picture of fluid status.
Monitor vital signs.	To establish baseline data and note changes.
Encourage oral intake.	To aid in replacing fluid losses.
Provide supplemental fluids as indicated.	Fluids may be given in this manner if client is unable to take oral fluids.
Administer medications as indicated.	To restore and rule out any underlying conditions.
Review appropriate use of medications.	Those that have potential for causing and exacerbating the present condition.

Anxiety

Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response.

May be related to

Situational crisis
Threat to self and/or fetus
Interpersonal tranmission

Possibly evidenced by

Increased tension
Fearful
Restless, jittery
Sympathetic stimulation

Desired Outcomes

Patient will use breathing and relaxation techniques effectively
Patient will cooperate with necessary preparations for a rapid delivery
Patient will follow directions and/or actively participate in delivery process

Nursing Interventions	Rationale
Maintain a calm, deliberate manner. Offer clear and concise instructions. Provide explanations.	An emergency or extremely rapid delivery occuring out of the hospital or in a hospital setting without the presence of a clinician can be extremely anxiety-provoking for the client or couple, who had anticipated an orderly progression trhough labor and delivery. When the actual birth event is not in keeping with their expectations, reactions may include hostility, fear, and disappointment. The composure of the nurse and her reassurance helps prevent or alleviate anxiety.
Provide a quiet environment and privacy within parameters of the situation. Position client for optimal comfort.	Reduces distractions and discomfort, allowing the client to focus. Helps reduce “contagious” anxiety of onlookers in or out of hospital delivery and supports modesty.
Encourage partner or SO to remain with the client, provide support and assistance as needed.	Allowing full participation by an SO enhances self-esteem, furthers cohesion of family unit, reduces anxiety, and provides assistance for the professional.
Remain with the client. Provide ongoing information regarding labor progression and anticipated delivery.	Reduces anxiety, fosters positive coping and cooperation, and reduces fear associated with the unknown.
Encourage appropriate coping or relaxation techniques.	Enhances sense of control; optimizes participation in the birth process.
Arrange for services of medical or nursing staff as soon as possible. Inform client that help has been requested.	The arrival of assistance helps the client or couple feel less anxious and more secure.
Conduct delivery in a calm manner; provide ongoing explanation.	Helps client remain calm and cooperate with instructions.
Place newborn on maternal abdomen once newborn respirations are established. Allow partner to hold infant.	Helps promote bonding and establishes a positive feeling about the experience.
Administer sedation as appropriate.	May help slow labor progress and allow client to regain control.

Risk for Infection

Risk factors:

Inadequate primary defense (e.g. skin)
Inadequate secondary defense (e.g. decreased hemoglobin)
Premature rupture of membranes

Possibly evidenced by:

[Not applicable]

Desired outcomes:

Patient will be afebrile and free from leucopenia.
Patient will verbalize understanding of individual risk factors.
Patient will identify interventions to prevent or reduce infection.
Patient will achieve timely wound healing.

Nursing Interventions	Rationale
Observe for localized signs of infection at the wound.	To establish presence of infection.
Stress proper hand hygiene by all caregivers between therapies and clients.	A first-line defense against healthcare-associated infections.
Recommend routine or preoperative body scrubs or showers when indicated	To reduce bacterial colonization.
Maintain sterile technique for all invasive procedures.	To prevent introduction of pathogens
Cover perineal dressings with plastic when using bedpan.	To prevent contamination.
Administer/monitor medication regimen and note client’s response.	To determine effectiveness of therapy or presence of side effects.
Emphasize necessity of taking antibiotics as directed.	Premature discontinuation of treatment when client begins to feel well may result in return of infection and potentiation of drug-resistant strains.
Discuss importance of not taking antibiotics or using leftover drugs unless specifically instructed by healthcare provider.	Inappropriate use can lead to development of drug-resistant strains or secondary infections.