Dystocia refers to difficult labor which is usually due to uterine dysfunction, fetal malpresentation/abnormality, or pelvic abnormality.
Nursing Care Plans
The nursing care for patients with dysfunctional labor revolves around identifying and treat abnormal uterine pattern, monitoring maternal/fetal physical response to contractile pattern and length of labor, providing emotional support for the client/couple and preventing complications.
- Risk For Maternal Injury
- Risk For Fetal Injury
- Risk For Fluid Volume Deficit
- Ineffective Individual Coping
Risk For Maternal Injury
- Risk for Injury
- Alteration of muscle tone/contractile pattern.
- Maternal fatigue.
- Mechanical obstruction to fetal descent.
Possibly evidenced by
- [Not applicable]
- Patient will accomplish cervix dilation at least 1.2 cm/hr for primipara, 1.5 cm/hr for multipara in active phase, with fetal descent at least 1 cm/hr for primipara, 2 cm/hr for multipara.
|Review the history of labor, onset, and duration.||Helpful in identifying possible causes, needed diagnostic studies, and appropriate interventions. Uterine dysfunction may be caused by an atonic or a hypertonic state. Uterine atony is classified as primary when it occurs before the onset of labor (latent phase) or secondary when it occurs after well-established labor (active phase).|
|Note timing/type of medication(s). Avoid administration of narcotics or of epidural block anesthetics until the cervix is 4 cm dilated.||A hypertonic contractile pattern may occur in response to oxytocin stimulation; sedation/analgesia given too early (or in excess of needs) can inhibit or arrest labor.|
|Note the condition of cervix. Monitor for signs of amnionitis. Note elevated temperature or WBC; odor and color of vaginal discharge.||A rigid or unripe cervix will not dilate, impending fetal descent/labor progress. Development of amnionitis is directly related to length of labor, so that delivery should occur within 24 hr after rupture of membranes.|
|Assess uterine contractile pattern manually (palpation) or electronically via external, or internal monitor with internal uterine pressure catheter (IUPC).||Dysfunctional contractions lengthen labor increasing the risk of maternal/fetal complications. A hypotonic pattern is reflected by frequent, mild contractions measuring less than 30 mm Hg via IUPC or “soft as chin” per palpation. A hypertonic pattern is reflected by increased frequency, an elevated resting tone per palpation or greater than 15 mm Hg via IUPC, and possibly decreased intensity of contractions. Note: Intensity of contractions cannot be measured by an external monitor.|
|Evaluate the current level of fatigue, as well as activity and rest prior to onset of labor.||Excess maternal exhaustion contributes to secondary dysfunction, or may be the result of prolonged labor/false labor.|
|Note effacement, fetal station, and fetal presentation.||These indicators of labor progress may identify a contributing cause of prolonged labor. For example, breech presentation is not as effective a wedge for cervical dilation as is vertex presentation.|
|Evaluate degree of hydration. Note amount and type of intake.||Prolonged labor can result in a fluid-electrolyte imbalance as well as depletion of glucose reserves, resulting in exhaustion and prolonged labor with increased risk of uterine infection, postpartal hemorrhage, or precipitous delivery in the presence of hypertonic labor.|
|Graph cervical dilation and fetal descent against time (i.e., Friedman curve).||May be used on occasion to record progress/ prolongation of labor.|
|Review bowel habits and regularity of evacuation||Bowel fullness may hinder uterine activity and interfere with the fetal descent.|
|Encourage client to void every 1–2 hr. Assess for bladder fullness over symphysis pubis.||A full bladder may inhibit uterine activity and interfere with the fetal descent.|
|Place client in lateral recumbent position and encourage bed rest or sitting position/ambulation,as tolerated.||Relaxation and increased uterine perfusion may correct a hypertonic pattern. Ambulation may assist gravitational forces in stimulating normal labor pattern and cervical dilation.|
|Have emergency delivery kit available.||May be needed in the event of a precipitous labor and delivery, which are associated with uterine hypertonicity.|
|Remain with the client if possible, arrange for the presence of doula as appropriate; provide a quiet environment as indicated.||Decrease external stimuli may be important to allow sleep after administration of medication to a client in the hypertonic state. Also helpful in decreasing the level of anxiety, which can contribute to both primary and secondary uterine dysfunction.|
|Palpate the abdomen of thin client for the presence of pathological retraction ring between uterine segments. (These rings are not palpable through the vagina or through the abdomen, in the obese client).||In obstructed labor, a depressed pathological ring (Bandl’s ring) may develop at the juncture of lowerand upper uterine segments, indicating an impending uterine rupture.|
|Investigate reports of severe abdominal pain. Note signs of fetal distress, cessation of contractions, presence of vaginal bleeding.||May indicate developing uterine tear/acute rupture necessitating emergency surgery. Note: Hemorrhage is usually occult since it is intraperitoneal with hematomas of the broad ligament.|
|Prepare client for amniotomy, and assist with the procedure, when the cervix is 3–4 cm dilated.||Rupture of membranes relieves uterine overdistension (a cause of both primary and secondary dysfunction) and allows presenting part to engage and labor to progress in the absence of cephalopelvic disproportion (CPD). Note: Active management of labor (AML) protocols may support amniotomy once presenting part is engaged to accelerate labor/help prevent dystocia.|
|Administer narcotic or sedative, such as morphine, pentobarbital (Nembutal), or secobarbital (Seconal), for sleep as indicated.||May help distinguish between true and false labor. With false labor, contractions cease; with true labor, a more effective pattern may happen following a rest. Morphine helps promote heavy sedation and eliminate hypertonic contractile pattern. A period of rest conserves energy and reduces utilization of glucose to relieve fatigue.|
|Use nipple stimulation to produce endogenous oxytocin or initiate infusion of exogenous oxytocin (Pitocin) or prostaglandins.||Oxytocin may be necessary to increase or institute myometrial activity for a hypotonic uterine pattern.It is usually contraindicated in hypertonic labor pattern because it can accentuate the hypertonicity, but may be tried with amniotomy if the latent phase is prolonged and if CPD and malpositions are ruled out.|
|Prepare for forceps delivery, as necessary.||Excessive maternal fatigue, resulting in ineffective bearing-down efforts in stage II labor, necessitates the use of forceps.|
|Assist with preparation for cesarean delivery, as indicated, e.g., malposition, CPD, or Bandl’s ring.||Immediate cesarean birth is indicated for Bandl’s ring or fetal distress due to CPD. Note: Once labor is diagnosed, if delivery has not occurred within 12 hr, and amniotomy and oxytocin have been used appropriately, then a cesarean delivery is recommended by some protocols.|
Recommended nursing diagnosis and nursing care plan books and resources.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
- NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
- Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
- Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
- Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
- All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other care plans related to the care of the pregnant mother and her infant:
- Abruptio Placenta | 3 Care Plan
- Cesarean Birth | 10 Care Plans UPDATED!
- Cleft Palate and Cleft Lip | 6 Care Plans
- Dysfunctional Labor (Dystocia) | 4 Care Plans
- Elective Termination | 6 Care Plans
- Gestational Diabetes Mellitus | 8 Care Plans UPDATED!
- Hyperbilirubinemia | 4 Care Plans
- Labor Stages, Induced and Augmented Labor | 36 Care Plans UPDATED!
- Neonatal Sepsis | 5 Care Plans
- Perinatal Loss | 5 Care Plans
- Placenta Previa | 3 Care Plans
- Postpartum Hemorrhage | 8 Care Plans UPDATED!
- Postpartum Thrombophlebitis | 5 Care Plans UPDATED!
- Prenatal Hemorrhage | 9 Care Plans UPDATED!
- Prenatal Substance Dependence/Abuse | 6 Care Plans
- Precipitous Labor | 3 Care Plans
- Preeclampsia and Gestational Hypertension | 6 Care Plans UPDATED!
- Premature Dilation of the Cervix | 3 Care Plans
- Prenatal Infection | 3 Care Plans
- Preterm Labor | 7 Care Plans UPDATED!
- Puerperal Infection | 4 Care Plans