6. Analysis/nursing diagnosis:
   1. Self-esteem disturbance related to perceived failure to give birth vaginally.
   2. Anxiety/fear related to impending surgery and/or reasons for cesarean birth.
   3. Ineffective individual coping related to anxiety and fear for self, infant.
   4. Fluid volume deficit related to abdominal surgery or reason for cesarean birth.
   5. Pain related to abdominal surgery.
   6. Constipation related to decreased bowel activity.
   7. Altered urinary elimination related to fluid volume deficit.
7. Nursing care plan/implementation:
   1. Preoperative:
      1. Goal: safeguard fetal status.
         1. Monitor fetal heart rate continually.
         2. Notify neonatology and neonatal intensive care unit (NICU) of scheduled surgical birth.
      2. Goal: health teaching.
         1. Describe, discuss anticipated anesthesia.
         2. Explain rationale for preoperative antacids to minimize effects of aspiration: cimetidine, Bicitra, histamine blocker to decrease production of gastric acid. Reglan (metoclopramide), to hasten gastric emptying.
         3. Describe, explain anticipated procedures - abdominal shave, indwelling catheter, intravenous fluids - to woman and support person.
      3. Other - as for any abdominal surgery.
      4. Prepare for cesarean birth.
   2. Postoperative:
      1. Same as for other abdominal surgical patients.
      2. Same as for other postpartum women.
8. Evaluation/outcome criteria:
   1. Verbalizes understanding of reasons for cesarean birth.
   2. Successful birth of viable infant.
   3. Evidences no surgical/birth complications.
   4. Evidences no interference with bonding.
   5. Expresses satisfaction with procedure and result.

5. Trial of labor after cesarean (TOLAC)
   1. Candidates for TOLAC.
      1. Previous low transverse cesarean birth.
      2. Head well-engaged in pelvis (vertex presentation).
      3. Soft anterior cervix.
      4. Preexisting reason for repeated cesarean birth not apparent.
   2. Assessment:
      1. Monitor FHR carefully during trial of labor.
      2. Monitor contractions carefully for adequate progress of labor.
      3. Observe mother for signs of complications/uterine rupture.
   3. Analysis/nursing diagnosis:
      1. Knowledge deficit related to trial of labor.
      2. Fear related to outcome for fetus.
      3. Ineffective individual coping related to labor progress and outcome.

Complications During the Intrapartal Period

1. General aspects
   1. Pathophysiology - interference with normal processes and patterns of labor/birth result in maternal or fetal jeopardy (e.g., preterm labor, dysfunctional labor patterns; prolonged [over 24] labor; hemorrhage: uterine rupture/inversion, amniotic-fluid embolus).
   2. Etiology:
      1. Preterm labor - unknown.
      2. Dysfunctional labor:
         1. Physiological response to anxiety/fear/ pain - results in release of catecholamines, increasing physical/psychological stress - myometrial dysfunction; painful and ineffectual labor.
         2. Iatrogenic factors: premature or excessive analgesia, particularly during latent phase.
         3. Maternal factors:
            1. Pelvic contractures.
            2. Uterine tumors (e.g., myomas, carcinoma).
            3. Congenital uterine anomalies (e.g., bicornate uterus).
            4. Pathological contraction ring (Bandl's ring).
            5. Rigid cervix, cervical stenosis/stricture.
            6. Hypertonic/hypotonic contractions.
            7. Prolonged rupture of membranes. Note: Intrauterine infection may have caused rupture of membranes or may follow rupture.
            8. Prolonged first or second stage.
            9. Medical conditions: diabetes, hypertension.
         4. Fetal factors:
            1. Macrosomia (LGA).
            2. Malposition/malpresentation.
            3. Congenital anomaly (e.g., hydrocephalus, anencephaly).
            4. Multifetal gestation (e.g., interlocking twins).
            5. Prolapsed cord.
            6. Postterm.
         5. Placental factors:
            1. Placenta previa.
            2. Inadequate placental function with contractions.
            3. Abruptio placentae.
            4. Placenta accreta.
         6. Physical restrictions: when confined to bed, flat position, etc.
   3. Assessment:
      1. Antepartal history.
      2. Emotional status.
      3. Vital signs, FHR.
      4. Contraction pattern (frequency, duration, intensity).
      5. Vaginal discharge.
   4. Analysis/nursing diagnosis:
      1. Anxiety/fear for self and infant related to implications of prolonged or complicated labor/birth.
      2. Pain related to hypertonic contractions/ dysfunctional labor.
      3. Ineffective individual coping related to physical/psychological stress of complicated labor/ birth, lowered pain threshold secondary to fatigue.
      4. High risk for injury related to prolonged rupture of membranes, infection.
      5. Fluid volume deficit related to excessive blood loss secondary to placenta previa, abruptio placentae, Couvelaire uterus, Disseminated Intravascular Coagulation.
   5. Nursing care plan/implementation:
      1. Goal: minimize physical/psychological stress during labor/birth. Assist woman in coping effectively:
         1. Reinforce relaxation techniques.
         2. Support couple’s effective coping techniques/mechanisms.
      2. Goal: emotional support.
         1. Encourage verbalization of anxiety/fear/ concerns.
         2. Explain all procedures - to minimize anxiety/fear, encourage cooperation/participation in care.
         3. Provide quiet environment conducive to rest.
      3. Goal: continuous monitoring of maternal/fetal status and progress through labor - to identify early signs of dysfunctional labor, fetal distress; facilitate prompt, effective treatment of emerging complications.
      4. Goal: minimize effects of complicated labor on mother, fetus.
         1. Position change: lateral Sims’ - to reduce compression of inferior vena cava.
         2. Oxygen per mask, as indicated.
         3. Institute interventions appropriate to emerging problems (see specific disorder).
   6. Evaluation/outcome criteria:
      1. Woman has successful birth of viable infant.
      2. Maternal/infant status stable, satisfactory.